Homelessness a cause, not a result of drug abuse

This article has gotten a lot of attention today. It runs counter to my admittedly biased experience and the experience of colleague who work in settings focused on homelessness. Note that it uses the term substance abuse rather than dependence. It's easy to believe that people with a diagnosis of substance abuse may have developed problems after becoming homeless. I find it more difficult to believe that people with substance dependence would have developed their problem only after becoming homeless.

It will be interesting to see the actual report and analysis of it:

A report on homelessness in Melbourne has shattered two key myths: that substance abuse and mental illness are the major reasons why people become homeless....

About 43 per cent had problems with substance use while 30 per cent reported mental health problems. Of these, 66 per cent and 53 per cent respectively had developed the problems after becoming homeless.

Home at Last

PBS's series NOW had a segment on a housing first approach with a man named Footie who is chronically homeless and an alcoholic. He's clearly a late stage alcoholic, frequently has seizures and may have some cognitive impairment due to years of heavy drinking and seizures. (Streaming video of the entire episode is available at the link above.)

The story made a pretty compelling case for this approach with this him, arguing that it was impossible to address his higher order needs when his physiological and safety needs were not being addressed. Footie was provided an apartment with no contingencies. The approach could make a lot of sense in many cases--the question is which cases and under what conditions?

I had several reactions to the segment. First, had Footie ever been provided with comprehensive treatment of and adequate dosage, duration? Why no contingencies? Maybe his housing shouldn't be contingent upon abstinence, but how about participation in treatment? If the fear is that this might be a set-up, how about reviewing it at monthly or quarterly intervals so that a bad week does not put him back on the street? Why not at least make it recovery-focused? If this approach is good for Footie and raises his functioning and quality of life to his potential, who's functioning and quality of life might be reduced to something below their potential? At Dawn Farm, we see some clients who would probably benefit greatly from a recovery-focused housing program that is not contingent upon abstinence. However, how many of clients who are currently in full recovery would have settled into an apartment like Footie's and never achieved stable recovery and a full, satisfying life? Many, I think.

UPDATE: This isn't to say it shouldn't be done, but rather how to go about it in a way that doesn't lower the bar for all homeless addicts and fail to address what caused their homelessness. Maybe one way to approach it is to ask, "Absent their addiction, would this person still be likely to be homeless?" In the case of Footie, the answer is "probably so". In the case of most of our homeless clients, the answer is "unlikely".

Of course, another big question is how to prioritize services in the context of scarce resources.

Stop-smoking efforts reaching out to homeless

Homeless shelters are beginning to look at addressing nicotine addiction. The discussion sounds lot like those that have taken place among treatment centers for the last decade:

Following successful anti-tobacco campaigns geared toward pregnant women, teenagers, African-Americans, Latinos and other groups, homeless people...may be the next target.

Amid broad skepticism, nascent campaigns to get the homeless off cigarettes are bubbling up in Chicago and across the country.

A Humboldt Park shelter is holding regular meetings where the homeless can discuss their addiction to tobacco. In New York City, Zyban and other anti-smoking pills will be distributed over the next few months at homeless shelters, where 6,000 workers also will be trained in tobacco physiology. Nicotine patches have been offered at shelters in Seattle since last fall and are on the way to others in Wisconsin.

Even cessation proponents acknowledge that small gains will be seen as a victory, considering that 80 percent of the chronically homeless are addicted to smoking.

The goal, experts say, is to change the culture in shelters and possibly save millions each year in Medicaid payments for smoking-related illnesses.

Increasingly, the homeless themselves are pushing the subject. At Humboldt Park Social Services, which operates in one of the Chicago's poorest neighborhoods, residents sit around a folding table during regular meetings to discuss tobacco.

"We started talking about what can kill you, talking about AIDS and STDs, but they didn't want to hear that anymore. . . . Our clients were tired of it," said Noemi Avelar, director of operations. "They wanted to talk about smoking. They said this is what we do every day, so let's take a look at it."

Addressing addictions to heroin, cocaine and marijuana remain priorities, but tobacco use will be added to the list beginning this year, said Avelar.

So far, few shelters have jumped on the anti-smoking wagon. Most cite higher priorities among their clients, including serious psychological problems or addictions to alcohol, heroin, methamphetamines and crack.

..."We have more people addicted to nicotine than heroin, and the cigarettes can be harder to quit," Harden said. "We'd love to address smoking along the way, but right now there isn't much out there that would do much good."

The executive director of Aurora's only permanent emergency shelter said tobacco addiction is a very low priority.

"I hate tobacco, but there are a lot more serious issues I have to deal with, starting with funding," said Ryan Dowd of Hesed House. "Sure, smoking is bad and causes all sorts of health problems. So does sleeping outside and not having anything to eat."

Randal Syverson, 56, a resident at Hesed House, was openly skeptical of cessation programs.

"No house, no job, no family--a cigarette can be the only joy I'll have today," he said.

I understand the reluctance of the program staff. Locally, they're underfunded and overwhelmed with the number of clients and the broad scope of their problems. An all out push toward smoking cessation doesn't fit neatly within their mission and their clients are clearly facing larger barriers to achieving stable housing. However, shelters perform all sorts of secondary public health functions and they can at least begin to change the culture among the homeless and in shelters--from one that celebrates tobacco to one that tolerates tobacco.

At the very least, providers should begin asking clients if they want to quit, said Janet Porter, program director for the National Network on Tobacco Prevention and Poverty.

"I think we've all been surprised by the number of the homeless who say, `yes,'" Porter said.

..."What's good for someone working at a big upscale law firm is just as good for people living in the street," said Roger Valdez, manager of the county's tobacco-prevention program. "Everyone deserves clean water, air and the same chance to beat this addiction."