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Long-Term Housing and Work Outcomes Among Treated Cocaine-Dependent Homeless Persons

Abstract

Communities across the United States have initiated plans to end chronic homelessness. In many of these communities, addiction treatment programs remain the default point of entry to housing and services. This study examined the percentage of cocaine-using homeless persons (all with psychiatric distress) attaining stable housing and employment 12 months after entering a randomized trial of intensive behavioral day treatment, plus one of the following for 6 months: no housing; housing contingent on drug abstinence; housing not contingent on abstinence. Of 138 participants, the percentages with stable housing and employment at 12 months were 34.1 and 33.3%, respectively. Analyses suggested superior outcomes in trial arms that offered housing as part of the behavioral treatment. The majority of participants, however, did not achieve housing or employment, in part because of the limited capacity of the local housing programs to accommodate persons who had not achieved perfect abstinence. The findings demonstrate a helpful role for addiction treatment and suggest the need for services to support housing of persons who reduce but do not eliminate all substance use.

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References

  1. 1.

    Burt MR, Hedderson J, Zweig J, et al. Strategies for reducing chronic street homelessness. Washington, DC: United States Department of Housing and Urban Development Office of Policy Development and Research 2004. Report No. Available at: http://www.urban.org/publications/1000775.html. Accessed September 30, 2006.

  2. 2.

    United States Interagency Council on Homelessness. City and County 10-Year Plan Update. Published; 2006: Available at: http://www.ich.gov/slocal/plans/10-year-plan-communities.pdf. Accessed July 21, 2006.

  3. 3.

    United States Department of Housing and Urban Development. Notice of Funding Availability (NOFA) for the Collaborative Initiative to Help End Chronic Homelessness. Published; 2003: Available at: http://www.hud.gov/offices/cpd/homeless/apply/2002nofa/index.cfm. Accessed September 30, 2006.

  4. 4.

    Editorial. Up and Off the Streets. New York Times. June 9, 2003; A:30.

  5. 5.

    Editorial. Ending Chronic Homelessness. New York Times. March 13, 2002; A:24.

  6. 6.

    Burt MR, Aron LY, Lee E, et al. Helping America’s Homeless: Emergency Shelter or Affordable Housing? Washington, DC: The Urban Institute Press; 2001.

  7. 7.

    Meyer IH, Schwartz S. Social issues as public health: promise and peril. American Journal of Public Health. 2000;90(8):1189–1191.

  8. 8.

    Wright JD, Rubin BA, Devine JA. Beside the Golden Door: Policy, Politics, and the Homeless. New York: Aldine de Gruyter; 1998.

  9. 9.

    Vangeest JB, Johnson TP. Substance abuse and homelessness: direct or indirect effects? Annals of Epidemiology. 2002;12(7):455–461.

  10. 10.

    The Secretary’s Work Group on Ending Chronic Homelessness. Ending Chronic Homelessness: Strategies for Action. Washington, D.C.: Department of Health and Human Services, USA 2003. Report No. Available at: http://aspe.hhs.gov/hsp/homelessness/strategies03/index.htm. Accessed September 28, 2006.

  11. 11.

    Burt MR, Aron LY, Douglas T, et al. Homelessness: Programs and the People They Serve. Technical Report of Findings of the National Survey of Homeless Assistance Providers and Clients. Washington, DC: Urban Institute 1999. Report No. Available at: http://www.huduser.org/publications/homeless/homeless_tech.html. Accessed September 28, 2006.

  12. 12.

    Substance Abuse and Mental Health Services Administration. Blueprint for Change: Ending Chronic Homelessness for Persons with Serious Mental Illnesses and Co-Occurring Substance Use Disorders. DNNS Pub. No. SMA-04-3870. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2003. Report No. Available at: http://mentalhealth.samhsa.gov/publications/allpubs/SMA04-3870/default.asp. Accessed September 30, 2006.

  13. 13.

    Orwin RG, Scott CK, Arieira C. Transitions through homelessness and factors that predict them: three-year treatment outcomes. Journal of Substance Abuse Treatment. 2005;28(Suppl 1):S23–S39.

  14. 14.

    Burnam MA, Morton SC, McGlynn EA, et al. An experimental evaluation of residential and nonresidential treatment for dually diagnosed homeless adults. Journal of Addictive Diseases. 1995;14(4):111–134.

  15. 15.

    Smith EM, North CS, Fox LW. Eighteen-month follow-up data on a treatment program for homeless substance abusing mothers. Journal of Addictive Diseases. 1995;14(4):57–72.

  16. 16.

    Lapham SC, Hall M, Skipper BJ. Homelessness and substance use among alcohol abusers following participation in Project H&ART. Journal of Addictive Diseases. 1995;14(4):41–55.

  17. 17.

    Conrad KJ, Hultman CI, Pope AR, et al. Case managed residential care for homeless addicted veterans. Results of a true experiment. Medical Care. 1998;36(1):40–53.

  18. 18.

    Sosin MR, Bruni M, Reidy M. Paths and impacts in the progressive independence model: a homelessness and substance abuse intervention in Chicago. Journal of Addictive Diseases. 1995;14(4):1–20.

  19. 19.

    Milby JB, Schumacher JE, Wallace D, et al. To house or not to house? Does it make a difference? American Journal of Public Health. 2005;95(7):1259–1265.

  20. 20.

    Milby JB, Schumacher JE. To House or not to house? Does it make a difference? American Journal of Public Health. 2005;95:1259–1265.

  21. 21.

    Milby JB, Schumacher JE, Raczynski JM, et al. Sufficient conditions for effective treatment of substance abusing homeless persons. Drug and Alcohol Dependence. 1996;43(1-2):39–47.

  22. 22.

    Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug and Alcohol Dependence. 2000;60(1):55–67.

  23. 23.

    United States Congress. Stewart B. McKinney Homeless Assistance Act. Public Law 100-77; 1987.

  24. 24.

    McNamara C, Schumacher JE, Milby JB, et al. Prevalence of nonpsychotic mental disorders does not affect treatment outcome in a homeless cocaine-dependent sample. American Journal of Drug and Alcohol Abuse. 2001;27(1):91–106.

  25. 25.

    Derogatis LR. The SCL-R-Manual I: Scoring, Administration and Procedures for the SCL-90. Baltimore, MD: Clinical Psychometric Research; 1977.

  26. 26.

    Iguchi MY, Belding MA, Morral AR, et al. Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use. Journal of Consulting and Clinical Psychology. 1997;65(3):421–428.

  27. 27.

    Hansten ML, Downey L, Rosengren DB, et al. Relationship between follow-up rates and treatment outcomes in substance abuse research: more is better but when is “enough” enough? Addiction. 2000;95(9):1403–1416.

  28. 28.

    Barrow S, Hellman F, Lovell A, et al. Personal History Form. In: Community Support Systems Evaluation Program, Epidemiology of Mental Disorders Research Department. New York State Psychiatric Institute; 1985.

  29. 29.

    Drake RE, McHugo GJ, Biesanz JC. The test–retest reliability of standardized instruments among homeless persons with substance use disorders. Journal of Studies on Alcohol. 1995;56(2):161–167.

  30. 30.

    Orwin RG, Scott CK, Arieira CR. Transitions through homelessness and factors that predict them: residential outcomes in the Chicago Target Cities treatment sample. Evaluation and Program Planning. 2003;26:379–392.

  31. 31.

    Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychologist. 1991;46(11):1115–1128.

  32. 32.

    Kowal J. Homeless alcoholics receive a permanent place to live, and drink. The New York Times. July 5, 2006; A:12.

  33. 33.

    Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health. 2004;94(4):651–656.

  34. 34.

    Gladwell M. Million-dollar Murray: why problems like homelessness may be easier to solve than to manage. The New Yorker. February 13, 2006:96–107.

  35. 35.

    Rosenheck R, Kasprow W, Frisman L, et al. Cost-effectiveness of supported housing for homeless persons with mental illness. Archives of General Psychiatry. 2003;60(9):940–951.

  36. 36.

    Orwin RG, Goldman HH, Sonnefeld LJ, et al. Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals: Final Evaluation Report. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism 1993. Report No.: NIH Pub. No. 93-3541.

  37. 37.

    Higgins ST, Budney AJ, Bickel WK, et al. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry. 1994;51:568–576.

  38. 38.

    Stitzer ML, Iguchi MY, Felch LJ. Contingent take-home incentive: effects on drug use of methadone maintenance patients. Journal of Consulting and Clinical Psychology. 1992;60(6):927–934.

  39. 39.

    Milby JB, Schumacher JE, McNamara C, et al. Initiating abstinence in cocaine abusing dually diagnosed homeless persons. Drug and Alcohol Dependence. 2000;60(1):55–67.

  40. 40.

    McLellan AT, Lewis DC, O’Brien CP, et al. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695.

  41. 41.

    Dennis M, Scott CK, Funk R. An experimental evaluation of recovery management checkups (RMC) for people with chronic substance use disorders. Evaluation and Program Planning. 2003;26(3):339.

  42. 42.

    Caton CL, Hasin D, Shrout PE, et al. Risk factors for homelessness among indigent urban adults with no history of psychotic illness: a case-control study. American Journal of Public Health. 2000;90(2):258–263.

  43. 43.

    Code of Federal Regulations, Shelter Plus Care, 24 C.F.R. 582.

  44. 44.

    Bipartisan Millennial Housing Commission. Meeting Our Nation’s Housing Challenges. Washington, D.C.: Congress of the United States; May 30, 2002. Report No. Available at: http://govinfo.library.unt.edu/mhc/MHCReport.pdf. Accessed September 30, 2006.

  45. 45.

    Simpson DD, Joe GW, Fletcher BW, et al. A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry. 1999;56(6):507–514.

  46. 46.

    Stahler GJ, Shipley TF, Jr., Bartelt D, et al. Evaluating alternative treatments for homeless substance-abusing men: outcomes and predictors of success. Journal of Addictive Diseases. 1995;14(4):151–167.

  47. 47.

    Kertesz SG, Horton NJ, Friedmann PD, et al. Slowing the revolving door: stabilization programs reduce homeless persons’ substance use after detoxification. Journal of Substance Abuse Treatment. 2003;24(3):197–207.

  48. 48.

    McLellan AT, McKay JR. The treatment of addiction: what can research offer practice. In: Lamb S, Greenlick MR, McCarty D, eds. Bridging the Gap Between Practice and Research: Forging Partnerships with Community-Based Drug and Alcohol Treatment. Washington, D.C.: National Academy Press; 1998:147–185.

  49. 49.

    Kraybill K, Zerger S. Providing Treatment for Homeless People with Substance Use Disorders: Case Studies of Six Programs. Memphis: National Health Care for the Homeless Council; August, 2003. Report No. Available at: http://www.nhchc.org/Advocacy/FactSheets/CA05RCaseStudies-FINAL5.pdf. Accessed June 5, 2005.

  50. 50.

    O’Brien CP. Anticraving medications for relapse prevention: a possible new class of psychoactive medications. American Journal of Psychiatry. 2005;162(8):1423–1431.

  51. 51.

    Beyond Shelter. The “Housing First” Program for Homeless Families: Methodology Manual. Los Angeles, California: Beyond Shelter, Inc.; 1998.

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Acknowledgments

Data collection, analysis, and manuscript preparation were supported by the National Institute on Drug Abuse (awards DA08475, DA11789, K23-DA15487). The author is grateful for the analytic assistance of Tony Horn, MS and Young-il Kim, MS.

Author information

Correspondence to Stefan G. Kertesz.

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Kertesz, S.G., Mullins, A.N., Schumacher, J.E. et al. Long-Term Housing and Work Outcomes Among Treated Cocaine-Dependent Homeless Persons. J Behav Health Serv Res 34, 17–33 (2007). https://doi.org/10.1007/s11414-006-9041-3

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Keywords

  • homeless persons
  • randomized controlled trials
  • addiction treatment
  • rehabilitative outcomes
  • employment
  • contingency management
  • health policy