Addiction Among The Homeless Population
As of 2019, 567,715 people in the United States were sleeping on the streets, in emergency shelters, or in transitional housing, according to the U.S. Department of Housing and Urban Development (HUD).1 Many of the individuals who lack a permanent residence suffer from substance abuse or mental health disorders that prevent them from finding safe living conditions. The HUD estimates that in 2019, 36% percent of the chronically homeless suffered from a chronic substance abuse problem, a severe mental illness, or both.1
There are many resources available for people who are experiencing homelessness or at risk of homelessness. However, connecting these individuals with the right housing programs or support groups can be challenging, especially if the individual is affected by substance abuse or mental illness.
What Causes Homelessness?
Rates of homelessness reflect trends in the country’s economy as well as factors in the individual’s physical and mental health and lifestyle. Homelessness is often the result of multiple factors leading to poverty and loss of material security.
The National Coalition for the Homeless (NCH) lists some of the key economic factors that contribute to homelessness in the US:2
- Inability to access healthcare/pay medical bills: Overwhelming medical costs is a major contributor to bankruptcy and poverty. A serious health emergency or disability can lead to homelessness.
- Loss of job opportunities: Many individuals are living in poverty and at risk of losing their housing due to unemployment. Even those who are employed may not make a salary high enough to lift them out of poverty.
- Lack of public assistance programs: Public assistance programs are becoming less available while the value they provide for families in need has decreased, resulting in a rise in poverty and homelessness.
- Inability to find affordable housing: At the same time, the national minimum wage stood at $7.25 per hour (and remains at this rate in 2020).4 Rising rental costs combined with a lack of housing assistance programs places low-income individuals and families in the difficult position of trying to pay higher housing costs on lower wages.
But financial woes are not the only reasons that people lose their homes. NCH also lists domestic violence, addiction, and mental illness as major factors that lead to the loss of permanent housing.2
Addiction and other psychological disorders often go hand-in-hand. Approximately 25% of individuals with a serious mental illness have a co-occurring substance use disorder.5 However, in homeless populations this percentage is doubled.6
Does Substance Abuse Cause Homelessness?
Substance abuse can be both the cause and the result of homelessness
Substance abuse can play a significant role in homelessness by making it difficult to perform well at a job. Job loss and chronic unemployment make it difficult to pay for housing, which can lead to eviction or foreclosure and eventually to homelessness. Addiction can exacerbate already existing financial problems and lead to loss of housing, as well.7
However, the National Coalition for the Homeless emphasizes that substance abuse can be both the cause and the result of homelessness, and that many people begin abusing alcohol or drugs after losing their homes in an attempt to cope with their situation. Unless substance abuse is treated, homeless persons are unlikely to regain the security or financial stability that can lead them out of poverty. 6
Having a substance use disorder can make it exceedingly difficult to for homeless people to find housing. Some housing assistance programs require that residents pass drug tests or enter and complete drug treatment before they can qualify for housing.8
When considering the problem of homelessness and substance abuse, it is important to remember that addiction is a chronic disease of the brain, not a sign of personal failure or a weak character.9 For those experiencing homelessness, recovery can be exceptionally difficult. First, recovery may be low on the priority list when each day requires an intense focus on obtaining food and shelter. Second, because addiction often causes estrangement from friends and family, recovery—which requires a good deal of social support—is that much more difficult. Third, recovery is a long-term pursuit that usually requires professional treatment and aftercare. Homeless individuals may have no health insurance and lack any transportation to get there. Without addressing these problems, it’s difficult for impoverished and homeless people to receive adequate rehabilitation.10
What Are the Common Drugs of Abuse?
Widely available and relatively inexpensive, alcohol is one of the most common substances of abuse in homeless populations, especially in older adults, notes the National Coalition for the Homeless.7 According to data taken in 7 Western countries, the most common substance use disorder among homeless individuals is alcohol dependence.11 Alcohol abuse contributes to many serious health problems that can be especially devastating for people with limited access to healthcare, including liver disease, cancer, heart disease, and stroke.12
The most commonly abused drugs include:13
- Heroin and prescription opioids. Heroin and prescription opioids are extremely addictive and carry a high risk of overdose.14,15 A 2014 study published in Drug and Alcohol Dependence found that among 457 homeless youth living in Los Angeles, 22 percent were currently abusing prescription drugs.16
- Methamphetamine. Methamphetamine is highly addictive and associated with many physical and mental health problems, including extreme weight loss, paranoia, cognitive problems, and overdose.17
- Cocaine. Crack cocaine, or freebase, is more prevalent among homeless populations than the powder form. Smoking crack cocaine is particularly detrimental to the respiratory and cardiovascular systems. Cocaine abuse causes serious mental side effects as well, including addiction, paranoia, and unpredictable behavior.18
Injection drug use (IDU) is common to those who struggle with addiction, especially with the drug types listed above. IDU greatly increases the risk of communicable diseases like HIV/AIDS and hepatitis. Increased risky sexual behaviors that arise from either loss of inhibition that arises from intoxication19 or that are part of “survival sex” (selling sex to survive on the street) also increases this risk.20
Another drug that seems to be highly prevalent among homeless populations is K2 or “spice.”13 While sometimes sold as a “safe” or legal alternative to marijuana, synthetic cannabinoids like K2 are often much more dangerous than the drug they attempt to imitate. Spice is addictive, and can cause unpredictable reactions, such as rapid heart rate, suicidal thoughts, and even overdose and death.21
It is very common for homeless people with substance use disorder to engage in polysubstance abuse (misuse of multiple substances simultaneously or concurrently),13 which complicates detoxification and subsequent rehabilitation.22
What Forms of Mental Illness Affect the Homeless?
The HUD estimates that around 20% of the homeless in the U.S. are severely mentally ill.1 Some of the most common forms of mental illness that affect individuals experiencing homelessness are as follows:23
Schizophrenia: This neurological disorder is characterized by episodes of psychosis, negative mood and motivation problems, and cognitive impairments. Symptoms of schizophrenia include:24
- Disorganized thinking and trouble focusing.
- Delusional beliefs.
- Bipolar disorder: People who struggle with bipolar disorder suffer dramatic shifts in mood, energy, and activity levels. Individual experiences shit from manic episodes—periods of high energy, which often coincide with feeling happy or irritable—to depressive episodes, which are characterized by feelings of significant sadness, apathy, or hopelessness.25
Major depression: Depression is common across all socio-economic classes; however, it is especially dangerous for people with limited resources and access to mental health care. Symptoms of depression include:26
- Persistent sadness and hopelessness.
- Chronic fatigue.
- Feelings of hopelessness.
- Insomnia or hypersomnia.
- Suicidal thoughts and behaviors.
The symptoms of severe mental illness can make it difficult or impossible to perform the activities that most of us take for granted, such as working, developing relationships, or maintaining a home.
Substance abuse and mental illness often co-exist. Individuals suffering from addiction and other psychological problems have a dual diagnosis or co-occurring disorders.27 As many as 50% of mentally ill homeless individuals suffer from a co-occurring substance abuse disorder.6
Substance abuse can also worsen the symptoms of mental illness by affecting the same areas of the brain that are impeded by certain psychological disorders. 28
A dual diagnosis can make treatment more complicated, because the symptoms of drug addiction or alcoholism can mask the symptoms of other mental illnesses.29 Clinicians working with homeless individuals must screen for both mental illness and substance abuse in their clients, and services for both conditions should be offered at the same time within the same treatment program in order to encourage retention and prevent a relapse.30
What Are the Barriers to Treatment?
When homeless people do receive mental health or substance abuse treatment, they may have difficulty following through with a therapeutic program or complying with a medication regimen. In general, drug treatment patients with dual diagnosis (approximately half the homeless people with substance use disorder)6 have poorer attendance and higher dropout rates than others.30
In a population whose members are in constant transition from one shelter, hospital, or jail to another, consistent treatment may be difficult or impossible to find. Also, while addiction can affect people from all demographics, there is still considerable social stigma that can make an individual hesitate to seek treatment.10
What Are Some Possible Solutions?
There are many volunteer groups, charitable organizations, churches, and government agencies working to improve the quality of life of homeless people with mental illness and/or substance use disorders. Effective outreach programs help to connect homeless individuals with services that can help them lead more secure, satisfying lives:
- Affordable therapy and counseling: Affordable, confidential mental health services for the homeless are often lacking. Publicly sponsored programs, like Care for the Homeless in New York City, offer counseling, psychotherapy and psychiatric consultation, primary care, and other services to assist the homeless.32
- Medication management: Psychiatric medication can be highly effective at treating the symptoms of schizophrenia, depression, bipolar disorder, and other serious forms of mental illness. 24, 25, 26 The National Healthcare for the Homeless Council provides resources to help people get the medication they need to manage mental illness.33
- Housing first programs: Housing first programs offer permanent housing to individuals in need without preconditions such as sobriety or lack of criminal history. These programs have proven efficacy in reducing homelessness, even among chronically homeless people with severe mental illness. There are low barriers to admission, and the individuals accepted are provided with voluntary treatment services and legal rights.34
- Substance abuse treatment: Treatment for substance use disorders has traditionally been viewed as a prerequisite for mental health treatment or housing services for the homeless. However, SAMHA emphasizes the importance of integrating substance abuse treatment with mental healthcare and housing in order to provide comprehensive, effective treatment.11
- Case management: Case managers work with public health agencies and other organizations to help those living without shelter build a support network and find safe, affordable housing. Case managers follow up with homeless clients to assess their mental status, ask about their needs, and help them find resources in the community to meet those needs.35
Supported housing services. Supported housing programs work to treat mental illness and provide stable housing simultaneously. These programs provide access to psychosocial services within the structure of a temporary or permanent living environment and may provide a range of services, including:36
- Regular visits from a home counselor.
- Individual therapy group therapy sessions.
- Assistance with transportation.
- Occupational counseling.
In a compassionate society, all members are treated with dignity and respect, regardless of their economic condition or health status. Meeting the basic needs of the homeless—for shelter, food, and healthcare—helps these individuals get to a point where they can begin to access treatment for mental illness and substance abuse.
- Housing First: Pathways to Housing: The “Housing First” model was developed to address the need for safe, supportive shelter among homeless people with chronic mental illness and substance use disorders. Unlike other housing models, Housing First takes the approach that homeless people who are actively abusing substances or who have serious mental illness should be provided with a place to live in order to benefit from treatment without any preconditions.
- Mental Health America (MHA): This community-based nonprofit organization has branches across the country that provide support, advocacy, and assistance for people suffering from mental illness. Resources on affordable housing, homelessness, and affordable mental health treatment are available on their website or through local MHA groups.
- National Alliance on Mental Illness (NAMI), “Finding Stable Housing”: NAMI offers a number of informational resources for people seeking help with homelessness, substance abuse, and psychiatric disorders. This guide provides advice on the types of housing available, how to find financial support for housing, and what to look for in a transitional or permanent dwelling.
- National Coalition for the Homeless (NCH): This national network of organizations, volunteers, and policymakers provides advocacy, outreach, and support for homeless Americans. Homeless individuals are actively engaged in NCH efforts to improve their lives and ensure affordable, secure housing.
- U.S. Department of Veterans Affairs (VA): Mental Health Services for Veterans: The U.S. Department of Veterans Affairs offers mental health services for homeless veterans, including a 24-hour telephone helpline, the National Call Center for Homeless Veterans: 1-877-424-3838.
- Federal Housing Resources Guide: The U.S. Department of Housing and Urban Development published this guide to publicly supported housing opportunities and federal funding programs for Americans who are homeless or at risk of homelessness.