COMMUNITY-ORIENTED APPROACHES TO OPIOID ABUSE AMONG THE
HOMELESS IN ALLEGHENY COUNTY: A LITERATURE REVIEW
by
Katie Lynn Naper
BA, Lawrence University, 2004
PharmD, University of Pittsburgh, 2012
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Katie L. Naper
on
December 11, 2015
and approved by
Essay Advisor:
David Finegold, MD
Director
Multidisciplinary MPH Program
Professor
Human Genetics
Graduate School of Public Health
University of Pittsburgh
_________________________________
Essay Readers:
Martha Ann Terry, PhD
Assistant Professor
Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
________________________________
Christina Mair, PhD
Assistant Professor
Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
________________________________
ii
Copyright © by Katie Naper
2015
iii
David Finegold, MD
COMMUNITY-ORIENTED APPROACHES TO OPIOID ABUSE AMONG THE
HOMELESS IN ALLEGHENY COUNTY: A LITERATURE REVIEW
Katie L. Naper, MPH
University of Pittsburgh, 2015
ABSTRACT
The magnitude of opioid abuse has reached epidemic levels as national survey data
reveal that 4.5 million people across the country abuse medications intended for pain relief.
Especially hard hit, all counties of southwestern Pennsylvania exceed the state’s mortality rate
for deaths due to prescription drugs. The co-occurrence of substance abuse and homelessness
has already been well established.
As the homeless population of Allegheny County has
increased, research that indicates drug overdoses have replaced HIV/AIDS as the leading cause
of mortality among the homeless, with 80% of drug overdose deaths attributable to opioids,
warrants concern.
This article presents a review of treatment options for the homeless
population with opioid use disorder which may be feasible to offer before securing housing,
based upon recently published literature.
A search of PubMed was conducted. It was restricted to English-language articles with
human subjects published between 2011 and 2015 that address therapies for opioid related
disorders among the homeless. The term “opioid related disorders” as a MeSH Major Topic
yielded 2,620 publications. The addition of the term “therapy” as a MeSH Subheading restricted
the list to 1,901 publications. Further applying “homeless” as a term to be searched in all fields
produced the final list of 15 publications. Review of these articles for relevance to the stated
topic produced three publications for consideration.
iv
Lessons gained from these programs demonstrate the importance of designing a public
health approach to offer treatment for opioid abuse to the homeless, including the use of
unconventional treatment sites, offering medication assisted treatment (MAT) and utilizing a
harm reduction approach to establish housing. As the number of programs available and referral
and utilization of the programs increase, special consideration should also be given to sources of
funding. While the design of this review captures only three studies, future research should
continue to examine social ecological influences on homelessness and opioid abuse to identify
feasible interventions. Healthcare stakeholders must consider the importance of complex social
ecological factors when determining how to address this epidemic and its immense financial and
humanistic costs.
v
TABLE OF CONTENTS
PREFACE .................................................................................................................................... IX
1.0
INTRODUCTION ........................................................................................................ 1
1.1
HOMELESSNESS AND SUBSTANCE ABUSE .............................................. 2
1.2
OPIOID PHARMACOLOGY AND ADDICTION .......................................... 4
1.3
MEDICATION-ASSISTED TREATMENT ..................................................... 5
2.0
METHODS ................................................................................................................... 7
3.0
RESULTS ..................................................................................................................... 9
3.1
THE MOBILE MEDICATION UNIT............................................................. 10
3.2
A COMMUNITY-BASED RECOVERY CENTER ....................................... 12
3.3
THE NEEDLE EXCHANGE PROGRAM ..................................................... 14
4.0
5.0
DISCUSSION ............................................................................................................. 15
4.1
UNCONVENTIONAL TREATMENT SITES ............................................... 15
4.2
PROVISION OF MAT ...................................................................................... 16
4.3
HARM REDUCTION APPROACH TO HOUSING ..................................... 16
4.4
PROGRAM FUNDING AND EXPANSION .................................................. 18
CONCLUSION........................................................................................................... 20
APPENDIX A: EXAMPLE RESOURCES IN ALLEGHENY COUNTY ............................ 23
BIBLIOGRAPHY ....................................................................................................................... 25
vi
LIST OF TABLES
Table 1. Studies reporting treatment strategies for opioid abuse amongst the homeless .............. 9
vii
LIST OF FIGURES
Figure 1. Flowchart of Selection of Peer-Reviewed Articles to Assess Recent (2011-2015)
Research on Therapies for Opioid Related Disorders among the Homeless .................................. 8
viii
PREFACE
The author would like to acknowledge the following individuals for their contributions to and
mentorship during the development of the research described in this essay:
From the University of Pittsburgh Graduate School of Public Health: Martha Terry, PhD
From Allegheny General Hospital:
Mary Lou Krieger, ACSW, LCSW; Laura Mark, MS,
PharmD, FASHP; Arvind Venkat, MD
ix
1.0
INTRODUCTION
The 2014 National Survey on Drug Use and Health identified that among the estimated
6.5 million people nationwide who use prescription drugs illicitly, 4.5 million, or 70%, are
abusing pain relievers (Substance Abuse and Mental Health Services Administration, 2014).
While abuse does not always develop into addiction, inappropriate use of prescription opioids
carries substantial risks for opioid-related fatalities (Cheatle, 2015).
Specifically in
Pennsylvania, mortality related to overdoses increased from 2.7 in 1990 to 15.4 overdose deaths
per thousand residents in 2011 (Pennsylvania Department of Drug and Alcohol Programs, 2014).
Locally, 2011 data from Allegheny County (AC) indicated that 20.5 people per 100,000 residents
died from drug overdoses, pointedly increased from 6.3 per 100,000 in 1990 (Crompton, 2014).
The Pittsburgh Post-Gazette identified prescription drug abuse as a particularly troubling in
southwestern Pennsylvania, noting that all southwestern Pennsylvania counties exceed death
rates across the rest of the state (Crompton, 2014).
Harrisburg, capital of the Commonwealth of Pennsylvania, also took notice of the
epidemic. The 2014 report by the Pennsylvania Department of Drug and Alcohol Programs
indicated that nearly 16% of the state’s budget, roughly $430 per capita, was spent on untreated
or undertreated alcohol and substance abuse problems. Recognizing the need for action, on
October 27, 2014, Pennsylvania Governor Tom Corbett enacted the Achieving Better Care by
Monitoring All Prescriptions Act (ABC-MAP) of 2014. The ABC-MAP Act was designed to
1
provide enhanced prescription drug monitoring in order to curb fraud and abuse. Among its
many supporters, the Pennsylvania Medical Society hailed the law for its potential to help
prescribers and dispensers (i.e. pharmacies) detect and stop “doctor shoppers” (Pennsylvania
Medical Society, 2014). The law was not so warmly received by all, however. Echoing previous
statements by the Office of National Drug Control Policy (2014), Andy Hoover, Legislative
Director American Civil Liberties Union of Pennsylvania, identified this as only part of the
solution. While solutions may include legal and regulatory action, it is time “to put more
investment into treatment and start addressing this as a public health issue” (Amtissal, 2014).
1.1
HOMELESSNESS AND SUBSTANCE ABUSE
Addressing an epidemic of opioid abuse warrants special consideration of social
ecological factors for distinct populations, particularly those already disenfranchised, such as the
homeless.
Research by Galea and Vlahov (2002) described how social factors, including
socioeconomic status and homelessness, are intertwined with drug use. The unsettling reality is
that between 2010 and 2014, AC witnessed a 25% increase in the homeless population from
1,265 to 1,573 people, as measured by the annual Point-in-Time survey required by the United
States Department of Housing and Urban Development (Allegheny County Department of
Human Services, 2015).
While the prevalence of individuals with severe mental illness
accounted for the largest subpopulation of the homeless (approximately 40%), the second most
prevalent subpopulation was individuals with chronic substance abuse (approximately 30%).
A recent study in Boston demonstrates cause for concern about substance abuse among
Pittsburgh’s homeless and reason to approach it as a public health matter. Baggett et al. (2013)
2
discovered a concerning shift in cause-specific mortality that developed over a 15 year time
period within the homeless population.
On the surface, all-cause mortality rates remained
unchanged between 1988-1993 and 2003-2008 cohorts of homeless individuals. Increases in
death due to drug overdose, however, were significant enough to make it the leading cause of
death, and also offset decreases in HIV/AIDS mortality such that the net effect on all-cause
mortality between cohorts was neutral.
Notably, Baggett et al. (2013) found that 80% of
overdose deaths were attributable to opioids. Reexamining their data from the 2003-2008 cohort
of 28,000 homeless individuals, Baggett et al. (2015) reported that drug-attributable mortality
was 8 to 17 times greater in homeless women and 10 to 14 times greater in homeless men
compared to the rest of the population.
Addressing either homelessness or substance abuse is independently complicated; the
combination of the two, however, truly represents a difficult situation. Choosing which issue to
address first presents a logistical challenge; whether it is more feasible to provide treatment for
substance abuse while someone remains homeless or to provide housing to someone with known,
ongoing substance abuse. For some time, the solution has been to provide housing assistance
conditional upon demonstrated and maintained abstinence (Henwood, Padgett, & Tiderington,
2014; Kertesz, Crouch, Milby, Cusimano, & Schumacher, 2009). A substance-free environment
may be conducive to achieving and maintaining an addiction-free life for some of the population;
however, for many homeless, finding food and shelter is more essential than drug counseling
(National Coalition for the Homeless, 2009).
The housing debate is far from over, however. Interviews with front-line providers
illustrate that strategies and treatment programs accepting of and prepared to address relapse as a
harm reduction strategy are more effective than abstinence-only programming (Henwood et al.,
3
2014). Housing First, a program developed by Tsemberis, Moran, Shinn, Asmussen, and Shern
(2003) and further reported on by Tsemberis, Gulcur, and Nakae (2004) provides housing to
those with mental health or substance abuse conditions without prerequisites for treatment or
sobriety. Their findings suggest people for whom housing is provided immediately, without
requirements for abstinence, are equally able to obtain and maintain that housing.
1.2
OPIOID PHARMACOLOGY AND ADDICTION
Addressing a public health problem such as the opioid epidemic also requires awareness
of individual-level risk factors. Understanding the effect prescription and illicit opioids have on
neurologic processes provides useful insight on both the development and treatment of addiction.
A variety of neurotransmitters has been implicated in the development of addiction, including
serotonergic, opioid, endocannabinoid, GABAergic, and glutamatergic mechanisms (Gardner,
2011).
The most directly responsible neurotransmitter is dopamine, levels of which are
increased in even simple pleasurable experiences. While research is still seeking to understand
the exact mechanisms of opioid addiction, scientific literature widely supports the association
between addictive drugs and activation of a common dopamine reward pathway (Furst, Riba, &
Al-Khrasani, 2013).
The connection between addictive pharmacologic opioids and the dopamine reward
pathway is understandable; the human body produces natural or endogenous opioids, commonly
involved in pain perception, reward, stress and autonomic control (Benarroch, 2012). Out of the
opioid receptor subtypes, stimulation of the mu and delta receptors facilitates the release of
dopamine. The central nervous system responds to repeated mu opioid receptor activation and
4
consequential floods of dopamine with desensitization and adaptive tolerance. The body may
develop tolerance to a variety of non-addictive substances. Tolerance for addictive substances
becomes problematic however as the user requires increasingly greater doses to achieve the
desired pain relief or pleasure.
Further use may lead to dependence, characterized as the
experience of withdrawal if the drug use is ceased (Feng et al., 2012; Gardner, 2011). At the
point that the individual exhibits a cluster of cognitive, behavioral and physiological symptoms
and continues to use the substance despite significant substance-related problems, he or she has
likely developed a substance use disorder (American Psychiatric Association, 2013).
1.3
MEDICATION-ASSISTED TREATMENT
A joint effort between clinicians and the Federal government, Adapting Your Practice:
Recommendations for the Care of Homeless Patients with Opioid Use Disorders, recommends
the medication-assisted treatment (MAT) be offered to any patient with an opioid use disorder
(Meges et al., 2014). Buprenorphine and methadone are the two most common medications used
in MAT for substance use disorders. Methadone, a synthetically derived opioid, acts as a
receptor agonist in that it stimulates the opioid receptors much like prescription opioid analgesics
and heroin (Roxane Laboratories, 2015). When given in sufficient doses once daily, the long
lasting effects of methadone make it possible to attenuate withdrawal and cravings associated
with substance use disorder. A highly regulated Schedule II substance, the prescription of
methadone for treatment of opioid addiction is subject to stringent Federal regulations
(Substance Abuse and Mental Health Services Administration, 2015).
State governmental
agencies may also impose additional requirements for its prescribing and dispensing.
5
Buprenorphine behaves similarly to methadone; however while methadone is a full mu
opioid agonist, buprenorphine is a partial agonist (Indivior, 2015). Like methadone, it is also
generally given once a day. Buprenorphine will not activate the mu opioid receptors to the same
degree as methadone and thus buprenorphine may be less appropriate for patients with high
levels of opioid dependence and tolerance (Whelan & Remski, 2012). Potential for abuse of
buprenorphine is decreased by combining it with the opioid reversal agent naloxone. When
taken orally as instructed, the naloxone has low bioavailability and will not affect the individual.
If, however, an individual attempts to abuse the combined buprenorphine and naloxone product
by way of dissolving and injecting it, the naloxone will trigger an antagonistic effect, producing
withdrawal symptoms. Listed as a Schedule III substance, buprenorphine is also highly regulated
by federal and state agencies.
Despite the best efforts of public health interventionists, there may be a variety of reasons
why a community cannot or will not support the Housing First model (Didenko & Pankratz,
2007). Bearing in mind the importance of patient-centered care, from a public health program
planning perspective, successful interventions will offer flexible services that can adapt to the
needs of individuals in AC, and the AC community itself. This paper presents a review of
treatment options for the homeless population with opioid use disorder which may be feasible to
offer before securing housing, based upon recently published literature.
6
2.0
METHODS
The United States National Library of Medicine’s PubMed electronic database was
accessed in October and November of 2015 using different combinations of Medical Subject
Headings (MeSH) and subheading search terms. The search was restricted to English-language
articles with human subjects published between 2011 and 2015 that address therapies for opioid
related disorders among the homeless. The term “opioid related disorders” as a MeSH Major
Topic yielded 2,620 publications. The addition of the term “therapy” as a MeSH Subheading
restricted the list to 1,901 publications. Further applying “homeless” as a term to be searched in
all fields produced the final list of 15 publications.
Inclusion criteria for these 15 publications required the article to address the homeless as
the population target, as opposed to reported as a demographic with no further analysis; the
article had to identify and describe the treatment as well as provide analysis of the outcomes as
they related to reducing or eliminating substance use; the substances of abuse had to include
opioids or heroin; and the article had to be available to access through the University of
Pittsburgh Health Sciences Library System. Of these 15 articles, two were identified that met all
inclusion criteria (Figure 1). One additional article was obtained and included as it was the
foundation for one of the two articles identified through the PubMed search.
7
Figure 1. Flowchart of Selection of Peer-Reviewed Articles to Assess Recent (2011-2015) Research on
Therapies for Opioid Related Disorders among the Homeless
8
3.0
RESULTS
Each of the three final selected publications reported on a program that took place in a
different state within the United States. Each used a unique modality for providing treatment
services. None of the three was provided directly out of a methadone clinic or physician’s office.
A summary and comparison of the programs is presented in Table 1.
Table 1. Studies reporting treatment strategies for opioid abuse amongst the homeless
Feature
Target
Population
Inclusion
Criteria
Exclusion
Criteria
Location
Study Design
Setting
Funding
Hall, et al., 2014
Disenfranchised individuals (e.g.
homeless, injection drug users and
uninsured)
 Household income at or below
350% of the Federal Poverty
Level
 Resident of New Jersey,
 History of injection drug use,
 Test positive for opioids,
 Not currently enrolled in opioid
replacement therapy
 Uninsured.
None specified
New Jersey (6 sites)
Prospective, Cohort
 Mobile medication units,
including a syringe exchange
service
 “Brick and mortar” methadone
clinics
 Public funding
 Blood borne Disease Harm
Reduction Act of 2006
Daniels, et al., 2014
Clients of a community
recovery center who were
unsuccessful in recovery
Opiate dependence (DSMIV)
Tringale, et al., 2015
Treatment-resistant poor,
urban, heroin-dependent
needle exchange patients
 Current heroin use
 Needle exchange
enrollment
Already receiving
medication-assisted
treatment for opioid
dependence
Baltimore, MD
Retrospective, descriptive
Community-based recovery
center (Dee’s Place)
 Positive methadone or
benzodiazepine use
 Heavy alcohol use
Los Angeles, CA
Prospective, descriptive
Community-based needle
exchange program
Grant funded
Grant funded (NIH)
9
Table 1. Continued
Feature
Available
Treatments
Abstinence
Testing or
Requirement
Role of
Homelessness
in the Study
Authors’
Recommendations
Hall, et al., 2014
 Buprenorphine/naloxone or
methadone
 Detoxification
 Diagnostic testing
 Case management
 Mental health services
 Little to no charge to
participants
None
Homeless, injection drug users and
uninsured were targeted
populations
 Need to address connection
between correctional/criminal
justice system and substance
abuse
 Public funding addresses the
barrier of affordability of
treatment
 Increase number of treatment
facilities and improve
geographic access
3.1
Daniels, et al., 2014
 Buprenorphine/naloxone
 Daily meetings on
recovery
 Weekly (Friday)
meetings on relapse
prevention
 Peer counselors
 No charge to participants
Testing – yes
Abstinence Requirement –
no
 Program sought to
provide service to people
who could/would not
otherwise access
 72% did not rent/own a
home
 18% living in
transitional/recovery
housing
 Providing buprenorphine
services at communitybased recovery center
can help increase
available treatment
options
 A community centerbased buprenorphine
program may hold
promise for increasing
access to and improving
substance use outcomes
among the most
underserved.
 Consider partnerships
between Substance
Abuse and Mental
Health Services Agency
and Accountable Care
Organizations and the
communities they serve
Tringale, et al., 2015
 Buprenorphine (22-day
course, including 15
days of detoxification)
 Peer support group
 Substance-abuse
counselors
Testing – yes
Abstinence Requirement –
no
Targeted initiative of the
Center for Harm Reduction
of Homeless Healthcare
Los Angeles
 Comprehensive, nonjudgmental
detoxification and harm
reduction reduces
treatment-resistant
needle exchange
patients reluctance to
enroll in long-term
maintenance therapies.
 Incorporate nontraditional settings into
drug treatment as a way
to enhance access to
care and recovery for an
underserved heroindependent population
THE MOBILE MEDICATION UNIT
Hall and colleagues sought to understand the barriers to MAT experienced by the
severely disenfranchised, including the homeless, uninsured and low-income populations by
10
conducting a prospective cohort study (Hall et al., 2014). Through legislative action in the state
of New Jersey, funding was provided for medication therapy (i.e. participants were offered the
choice of either methadone or buprenorphine) and a mobile medication unit (MMU) that made
two stops per day, six times per week, at six sites across the state. Each van was affiliated with a
traditional office-based methadone clinic. Areas for visitation were identified based on their
high prevalence of HIV and injection drug users (IDUs), homeless and uninsured.
This
community-based service was offered at little to no charge on a walk-in basis. The MMUs were
equipped and staffed to also provide sterile syringe exchange, blood borne disease and STD
testing, cognitive behavioral therapy, case management and connections to and financial support
for other substance abuse treatment. Notably, case managers assisted participants with applying
for Medicaid and provided counseling on employment and education opportunities. The MMU
clients were compared to those who utilized methadone MAT via the traditional office-based
methadone clinic as well as those who received treatment at the same location but did not receive
MAT.
Based upon clients enrolled between 2008 and 2010, compared to participants receiving
MAT from a traditional clinic, MMU clients were older, more likely to be African American or
Latino, have less social capital (i.e. less likely to be married and more likely to be homeless or
uninsured), more likely to be IDU and have a diagnosis of mental illness. The study also showed
that of the 25% of clients that elected buprenorphine MAT, these clients were more likely to be
African American, Latino and non-IDUs.
The recommendations of Hall et al. (2014) included increasing public funding to reduce
barriers of affordability for treatment to the disenfranchised population, as well as to increase the
number of available treatment facilities and geographic access. The MMU system was able to
11
provide outreach to a population greatly in need of treatment an otherwise virtually unable to
obtain it.
3.2
A COMMUNITY-BASED RECOVERY CENTER
Bringing the services to the population was also described in a retrospective, descriptive
study by Daniels, Salisbury-Afshar, Hoffberg, Agus and Figerhood in 2014, conducted at a site
in Baltimore, MD known as “Dee’s Place.” The aims of the study were to describe clients
served by a buprenorphine program in a community-based recovery center and present initial
treatment outcomes. The goal was to engage the recovery center population in treatment and
once stable and insured, transition them to continued treatment in a primary care setting.
The unique feature of this program was the treatment’s colocation with the recovery
center, which also hosted 12-Step meetings and connected participants with support services
such as housing, legal assistance, health and mental health needs. In this case, the staff of Dee’s
Place had approached the local nonprofit Behavioral Health Leadership Institute about providing
treatment services at the center. While the primary goal of the center was not to provide
treatment for opioid abuse, it nonetheless recognized that many people in the community were in
need of services and would otherwise be unable to access them. On a weekly basis a team of a
physician, nurses, counselors, a case manager and community outreach worker made contact
with each participant at Dee’s Place. Prescriptions for up to a week’s take-home supply of
buprenorphine/naloxone were paid for by grant funding and provided to participants free of
charge.
12
Other features of the treatment program included daily to weekly contact with a nurse or
case manager, urine drug screening, daily Narcotics Anonymous meetings as well as weekly
relapse prevention meetings. While urine drug screens were monitored for the presence of
buprenorphine and opiates, abstinence was not a requirement of continuation in the program;
rather, the presence of opioids in the participant’s urine indicated to the clinical team that he or
she needed additional support. For this reason, Dee’s Place provided “recovery coaching”
through a team of counselors who have received additional training by the state-funded
Baltimore Substance Abuse Services agency.
adherence and opiate abstinence.
Outcome measures included buprenorphine
A successful participant obtained health insurance and
established continued treatment with a community primary care provider.
Demographics from the Daniels, et al. (2014) study indicate that among the 78
individuals from that population who received treatment, 78% were African American and 55%
were males. Approximately 72% did not own or rent their own home, 18% of whom were living
in transitional or recovery housing. Overall, the average length of treatment for all clients was
13.5 weeks, during which the mean percent of opiate-abstinent weeks was 83% and
buprenorphine-adherent weeks was 95%.
Approximately half of all participants were
successfully transitioned to primary care-based treatment, with no statistically significant
differences between those who transitioned and those who did not. Successfully transitioned
clients did, however, have a significantly longer time in treatment than those who did not, with
respective means of 20.5 weeks versus 6.9 weeks.
Daniels, et al. (2014) arrived at the conclusion that treatment needs to be provided in the
areas of need. Buprenorphine programs are less restrictive than those to operate a methadone
clinic, thus may be a practical option to in these settings. Treatment services at a recovery center
13
were able to access a marginalized group of people who were identified by their own
community.
3.3
THE NEEDLE EXCHANGE PROGRAM
Following publication of the Daniels, et al. (2014) study, a group of Los Angeles
colleagues submitted a letter to the editor of the Journal of Addiction Medicine (Tringale, Subica,
Danielian, & Kaplan, 2015). A non-traditional drug treatment center, the Center for Harm
Reduction of Homeless Healthcare Los Angeles sought to help treatment-resistant, poor, urban,
heroin-dependent patients transition to opioid maintenance therapy as a harm reduction strategy.
As a pilot study with nine patients, Tringale et al. sought to identify the potential for a program
that appealed to this population based on its non-judgmental philosophy and acceptance of
relapse, 15-day buprenorphine detoxification supported by peers and daily provider dispensed
dosing and certified substance abuse counselors. Participants were identified through a local
needle exchange program. Of note, patients who tested positive for benzodiazepine use were
excluded from the study, due to risk of overdose.
Of the seven patients who completed the 22-day program, six were successfully
transitioned to long-term MAT. Participants reported that the ability for buprenorphine to reduce
cravings and stabilize cognition and emotional processing, permitted use of opiates and illicit
substances and long-term treatment goal planning were strengths of the program.
investigators openly acknowledged the size of their study as a significant limitation.
14
The
4.0
DISCUSSION
Many aspects of the three programs previously described are consistent with
recommendations put forth by Health Care for the Homeless Clinicians’ Network (2014),
developed with support from the Bureau of Primary Health Care, Health Resources and Services
Administration and U.S. Department of Health and Human Services. This review presented
several important themes to designing a public health approach to offer treatment for opioid
abuse to the homeless, including the use of unconventional treatment sites, offering MAT and
utilizing a harm reduction approach to establish housing.
As part of the evaluation for any
intervention, consideration is also given to funding of these programs.
4.1
UNCONVENTIONAL TREATMENT SITES
The most salient feature of these three programs was their novel approach to providing
treatment to a marginalized population through unconventional treatment sites.
Both the
Assistant Surgeon General’s 1999 report on Principles of Practice, A Clinical Resource Guide
for Health Care for the Homeless (Health Resources and Services Administration, 1999) as well
as the 2014 report from the Health Care for the Homeless Clinicians’ Network guide Adapting
Your Practice: Recommendations for the Care of Homeless Patients with Opioid Use Disorders
(Meges et al., 2014) support utilization of community-based models for the treatment of opioid
15
addiction among the homeless. The programs featured here established treatment in areas where
the homeless were known to be found and by doing so, each program found a way to bring
services to people who otherwise did not have the resources to seek treatment or feel comfortable
in a traditional office or clinic setting.
4.2
PROVISION OF MAT
All three programs included in this review also made use of MAT. This is consistent
with guidelines developed by agencies of the federal and Pennsylvania government to guide
clinicians and healthcare advocates to take on the opioid epidemic (Mann, Frieden, Hyde,
Volkow, & Koob, 2014; Meges et al., 2014; Pennsylvania Department of Drug and Alcohol
Programs, 2014).
All three of the programs described herein offered treatment with
buprenorphine; only Hall et al. (2014) additionally offered methadone. Despite their lack of
stable housing, the clinicians and research teams involved felt that under supervision and with
evidence-based behavioral therapies, MAT is a safe and cost-effective manner of treating opioid
and heroin substance use disorders.
4.3
HARM REDUCTION APPROACH TO HOUSING
The third theme of these programs was taking a harm reduction approach to establishing
housing for people seeking recovery. Doing so acknowledges the complexity and resources that
must be involved to overcome homelessness and opioid abuse. While Daniels, et al. (2014) and
16
Tringale, et al. (2015) incorporate drug screening as part of their protocols, relapse did not
exclude people or result in dismissal from the program; rather, it was used to identify individuals
who needed additional support.
This is important to consider when assessing treatment programs available to the
homeless of western Pennsylvania. In AC alone there were over 1,500 homeless individuals
(excluding those in permanent supportive housing), 93% of whom had access to shelter (i.e. a
primary nighttime residence that is a supervised shelter designed to provide temporary living
accommodations, including both emergency shelters and transitional housing) (Allegheny
County Department of Human Services, 2015). While considered shelter, it is unclear whether
these provide sufficient stability and security to foster recovery from opioid abuse. Furthermore,
while AC has a capacity of approximately 1,000 beds in transitional or permanent supportive
housing, for some, mandatory abstinence restricts access to initial or continued housing if a
person should relapse (Burger, Horn, Bell, & Dalton, 2015; Familylinks, 2014). Therein lays the
advantage of the three programs previously described: their ability to provide treatment despite
the lack of stable housing.
As part of a preliminary assessment of services for the homeless in AC, focus groups
with clients of the AC homelessness service system revealed that strict “clean-time” and
background check requirements made it difficult to find a housing program (Horn, Whitehill, &
Yonas, 2015). The importance of changing this experience was supported by the Pennsylvania
Department of Drug and Alcohol Programs in their 2014-2015 strategic plan, which outlined the
need to expand access to and availability of resources to support homeless with substance use
disorders (Pennsylvania Department of Drug and Alcohol Programs, 2014).
A number of
agencies have also endorsed program guidelines that also services such as the management of
17
concurrent physical and mental health issues as well as employment services (Mann et al., 2014;
National Coalition for the Homeless, 2009; National Health Care for the Homeless Council,
2011). This comprehensive approach addresses the complicating factors that make recovery
from opioid abuse especially difficult for the homeless.
4.4
PROGRAM FUNDING AND EXPANSION
Implementation of all three programs described by Hall et al. (2014), Daniels et al.
(2014) and Tringale et al. (2015) was supported by public or grant funding. Identification of new
funding streams will be critical for successful implementation of new programs or expansion of
existing programs in AC, which may include receipt of federal grants. Encouraging statements
by the federal government have suggested that several regulatory changes and funding
opportunities are on the horizon.
Health and Human Services Secretary Sylvia Burwell
announced the agency’s plans to revise Federal regulations in order to expand access to
buprenorphine treatment as well as award $1.8 million in grants to support community
partnerships, including facilitating referrals to substance abuse centers (Burwell, 2015). Previous
research has presented a number of reasons why chronic heroin users put off seeking health care,
which may contribute to inappropriate use of the emergency departments (McCoy, Metsch,
Chitwood, & Miles, 2001). Hospitals and emergency departments therefore may be suitable
environments to help identify individuals ready to accept treatment and connect them to
community services (McNeil, Kerr, Pauly, Wood, & Small, 2015).
With increasing numbers of programs and increasing referrals to programs, the demand
for funding will consequentially increase. Financial support to provide MAT for the homeless
18
will need included in any program proposal. Pennsylvania’s Medicaid program presently covers
both buprenorphine and methadone for those that are enrolled (Pennsylvania Department of
Human Services, 2015); however, not all homeless may be enrolled. Despite the efforts of the
Affordable Care Act, data from the 2014 National Health Care for the Homeless Program
suggest that 43.1% of homeless patients are uninsured; this may in fact an underestimate, as it
was based solely on patients presenting to the Health Care for the Homeless programs (Health
Resources and Services Administration, 2014).
Fortunately, AC already has a number of organizations to effect positive change in opioid
abuse among the homeless in AC (Appendix A). At present, organizations such as Prevention
Point Pittsburgh, Familylinks and Operation Safety Net are already operational and providing
health interventions to the homeless.
Leveraging their established relationships with the
homeless community and expanding provision of MAT, possibly by developing novel outreach
efforts like the three presented here, will be an essential part of the public health strategy for
treating the opioid epidemic.
19
5.0
CONCLUSION
The magnitude of opioid abuse has reached epidemic levels as national survey data reveal
that 4.5 million people across the country abuse medications intended for pain relief. Especially
hard hit, all counties of southwestern Pennsylvania exceed the state’s mortality rate for deaths
due to prescription drugs. The co-occurrence of substance abuse and homelessness has already
been well established. As the homeless population of AC has increased, research that indicates
drug overdoses have replaced HIV/AIDS as the leading cause of mortality among the homeless,
with 80% of overdose deaths attributable to opioids, warrants concern. This article presents a
review of treatment options for the homeless population with opioid use disorder which may be
feasible to offer before securing housing, based upon recently published literature.
A search of PubMed has produced three studies published in the last five years on unique
programs. Lessons gained from these programs demonstrate the importance of designing a
public health approach to offer treatment for opioid abuse to the homeless, including the use of
unconventional treatment sites, offering MAT and utilizing a harm reduction approach to
establish housing. As the number of programs available and referral and utilization of the
programs increase, special consideration should also be given to sources of funding. While the
design of this review captures only three studies, future research should continue to examine
social ecological influences on homelessness and opioid abuse to identify feasible interventions.
20
Healthcare stakeholders must consider the importance of complex social ecological factors when
determining how to address this epidemic and its disturbing financial and humanistic costs.
The most prominent limitation of this review is the capture of only three publications in
the last five years. This may be attributable to the search methodology described, as utilized in
PubMed.
While homelessness is often reported as a demographic factor, this review was
dependent upon the term “homeless” as part of its search parameter. The review also targeted
studies specifically aimed at the homeless. It is likely that a variety of other treatment strategies
may be adaptable to this population, although they have not been published as being focused on
the homeless. The search was also limited to English-only articles. Other indexed databases of
research may also provide additional relevant articles.
Future investigation should continue to follow the social ecological model to identify
successful methods of treatment, as this public health problem is far too large and complex to be
solved at any one level alone. Directly involving peers of the homeless and recovered formerly
homeless individuals in the design of interventions, as Daniels et al. (2014) and Tringale et al.
(2015) did, would be beneficial as they can draw upon their own experiences and relationships
with this community. The qualitative research by McNeil et al. (2015) demonstrates the insights
that can be gained through semi-structured interviews in order to better understand the
perspective of this population.
Both of these approaches will help to develop feasible
interventions that are culturally sensitive to the homeless population.
The potential financial and humanistic costs of healthcare stakeholders failing to respond
to this epidemic are perhaps most unsettling. Prescription opioid abuse, dependence and misuse
were estimated to have incurred societal costs estimated at $55.7 billion from 2003 to 2007 alone
(Birnbaum et al., 2011). Left unaddressed, at current mortality rates, 44 people across the nation
21
will continue to die on a daily basis due to opioid overdose (Centers for Disease Control and
Prevention, 2015Centers for Disease Control and Prevention, 2015).
When developing
interventions to address the epidemic, public health advocates and clinicians must remember that
it will not be a model of “one size fits all”; rather, applying the social ecological model to
understand complex factors and design community-oriented approaches will be critical to
reigning in the costs of abuse and reaching even the most marginalized members of society.
Healthcare stakeholders must consider again the findings presented by Baggett et al.
(2013), demonstrating that drug overdose, particularly related to opioid analgesics and heroin,
has replaced HIV/AIDS as the leading cause of death of homeless adults. Advances in antiviral
medicine have transformed HIV/AIDS from a deadly condition into a chronic disease state,
making it possible for many, including the homeless, to live longer, healthier lives. Yet it seems
cruelly ironic that substance abuse, including opioid medications, has now become their primary
cause of mortality.
22
APPENDIX A: EXAMPLE RESOURCES IN ALLEGHENY COUNTY
Operation Safety Net
Website: https://www.pmhs.org/operation-safety-net/
Purpose: As long as there are unsheltered homeless sleeping on our streets, in our abandoned
buildings, and along our riverbanks, Operation Safety Net will provide access to health care that
is designed to meet their unique needs. Program activities include:
 Street Outreach: Walking teams of clinicians and formerly homeless workers provide
care in the streets.
 Case Management: Patients are given a supportive environment to help them plan their
own recovery.
 Computerized Database: OSN is a pioneer in applying information technology with
health care treatment.
 Medical Services Mobile Van: The van is a physician's office on wheels that travels to
distressed areas afflicted by poverty, drugs and crime.
 WellSpring Drop-in Clinic: Primary care services, free of charge, are provided in a
physician office complex.
 Medical Education: OSN trains future physicians and clinicians to provide care to the
poor.
 Projects:
OSN builds community through public health partnerships, housing
connections, research studies, and local as well as national leadership roles.
Prevention Point Pittsburgh
Website: www.pppgh.org/services
Prevention Point Pittsburgh (PPP) is a nonprofit organization dedicated to providing health
empowerment services to injection drug users.
In addition to needle exchange services, PPP has grown to include comprehensive case
management services, assistance to drug treatment, individualized risk-reduction counseling,
health education, condom and bleach distribution, overdose prevention with Narcan prescription,
23
and free HIV, Hepatitis C, and syphilis screening in collaboration with the Allegheny County
Health Department.
Familylinks
Website: www.familylinks.org




Penn Free Bridge Housing: Penn Free Bridge Housing offers secure housing to people
ages 18 and older who are homeless and in recovery from alcohol or drug abuse, who
have been referred via Allegheny Link. The program provides:
o Secure, financially-supported accommodations for individuals and/or families for
up to one year
o Supportive services in areas such as employment, education, counseling, legal
issues, medical support and household needs
o Bus tickets and passes as needed
o Assurance of recovery program, including random urine tests
To qualify for admission to Penn Free Bridge Housing, individuals must be:
o 18 years or older
o Earning less than 200% of the federal poverty guideline limit
o Homeless by County definition and referred via the Allegheny Link housing list
o Chemical-free for a minimum of 90 days
o In treatment for substance abuse, or actively involved in recovery
Shelter Plus Care Program: Familylinks realizes that some people need support on an
ongoing basis. Shelter Plus Care Program provides permanent housing and case
management services for people and families that are homeless and have disabilities,
including mental health issues and/or substance abuse.
Federally funded by the Department of Housing and Urban Development, Shelter Plus
Care may subsidize up to 100% of rent, depending on an individual's income.
24
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