Laying the foundations: addressing heroin use among the 'street homeless'

The lack of secure housing can exacerbate the health problems associated with injecting drug use. The lack of hygiene, security and personal organization that are part of a transient lifestyle increases the tendency towards, and exposure to, risky drug use behaviours with implications for both the drug user and the wider community. However, homeless drug users have little realistic hope of better 'managing' drug use without access to secure accommodation as a first step. Drug treatment and health care services are not sufficiently structured to meet the particular needs of homeless individuals. This paper acts as a 'conduit' for the words of heroin users to demonstrate, from their perspective, the need for housing provision and the dangers of injecting drug use in marginal living environments. It closes with a short discussion of how housing must be integrated with further support services if users are not to relapse.     

Matching Clients’ Needs With Drug Treatment Services

This paper reports results of a study that investigated whether matching drug treatment services with client needs improved outcomes for a sample of 171 clients who participated in community-based drug treatment programs. Clients were initially assessed on multiple problem areas (alcohol use, drug use, medical, psychological, family/social, legal, employment, housing) and on areas of special needs or stated preferences for services (e.g., transportation, child care, language). A 6-month follow-up interview reassessed clients’ problems/needs in all areas and collected information on the services received. The results showed that some services significantly improved client outcome for those who had expressed needs for such services. Notably, services meeting the need for vocational training, child care, transportation, and housing showed beneficial effects. A higher level of needs and services matching (defined either by the ratio of services received to services desired, or by the total level of met versus unmet needs in the eight problem areas) significantly predicted longer treatment retention.     

The Association Between Stimulant,Opioid, and Multiple Drug Use on Behavioral Health Care Utilization in a Safety-Net Health System

Background: Prior studies show an association between drug use and health care utilization. The relationship between specific drug type and emergent/urgent, inpatient, outpatient, and behavioral health care utilization has not been examined. We aimed to determine if multiple drug use was associated with increased utilization of behavioral health care. Methods: To assess health care utilization, we conducted a retrospective cohort study of patients who accessed health care at a safety-net medical center and affiliated clinics. Using electronic health records, we categorized patients who used stimulants, opioids, or multiple drugs based on urine toxicology screening tests and/or International Classification of Diseases, 9th Revision (ICD-9). Remaining patients were categorized as patients without identified drug use. Health care utilization by drug use group and visit type was determined using a negative binomial regression model. Associations were reported as incidence rate ratios. Utilization was described by rates of health care–related visits for inpatient, emergent/urgent, outpatient, and behavioral health care among patients who used drugs, categorized by drug types, compared with patients without identified drug use. Results: Of 95,198 index visits, 4.6% (n = 4340) were by patients who used drugs. Opioid and multiple drug users had significantly higher rates of behavioral health care visits than patients without identified drug use (opioid incidence rate ratio [IRR] = 7.2; 95% confidence interval [CI]: 3.8–13.8; multiple drug use IRR = 5.6, 95% CI: 3.3–9.7). Patients who used stimulants were less likely to use behavioral health services (IRR = 1.3, 95% CI: 0.9–2.0) when compared with opioid and multiple drug users, but were more likely to use inpatient (IRR = 1.6, 95% CI: 1.4–1.8) and emergent/urgent care (IRR = 1.4, 95% CI: 1.3–1.5) services as compared with patients without identified drug use. Conclusions: Integrated medical and mental health care and drug treatment may reduce utilization of costly health care services and improve patient outcomes. How to capture and deliver primary care and behavioral health care to patients who use stimulants needs further investigation.     

建立突发公共卫生事件国家药品应急体系的设想

目的 :提高突发公共卫生事件中药品相关部门的应急能力。方法 :设想建立突发公共卫生事件国家药品应急体系。结果 :药品应急体系必须重视应急药品储备、应急能力储备、应急信息储备和应急预案储备。结论 :突发公共卫生事件国家药品应急体系的建立是促进医疗卫生现代化建设的一个契机     

Magdalena Pilot Project: motivational outreach to substance abusing women street sex workers

The Magdalena Pilot Project provided outreach to Albuquerque women sex workers who were also using illicit drugs, primarily cocaine and heroin. This initial uncontrolled trial evaluated the feasibility and potential impact of motivational interviewing (MI) on change in drug use and HIV risk behaviors. Twenty-seven women were enrolled and interviewed about their substance use, health risk behaviors, and plans for change, using the client-centered, directive method of MI. Four months later, 25 women (93%) were interviewed again to assess their drug use and health risk behaviors. Large reductions were reported in frequency (days) of drug use and sex work, with a corresponding increase in days of lawful employment. In identifying problems that most needed to be addressed in order to help them live healthier lives, the women prioritized (1) basic needs including decent housing, (2) mental health care, and (3) treatment for substance use disorders.     

突发性公共卫生事件中的药品安全研究

目的:为提高突发性公共卫生事件中的药品安全性提供参考。方法:通过对突发性公共卫生事件中用药需求特点的分析,明确事件发生期间药品安全的特点,以此为基础探讨有效的保障策略。结果与结论:保障突发性公共卫生事件中的药品安全需要进行专门的制度设计和对策研究,其立足点主要围绕充分的事前保障、迅速的事中响应以及及时的事后完善3个层次。     

Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada

Aims: Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision. Methods: EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada. Findings: The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges. Conclusions: Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.     

Homelessness,substance misuse,and access to public entitlements in a soup kitchen population

The study examined the effects of homelessness on access to public entitlements (Medicaid and food stamp programs) in a soup kitchen population. Data were collected between 1997 and 1999 from a sample of 343 adults at two soup kitchen sites in New York City. Five hypotheses, focusing on the effects of housing status (literal homelessness, unstable housing, and domiciled), frequency of drug/heavy alcohol use, drug/alcohol-user treatment history and childcare responsibilities on access to Medicaid and food stamp programs were tested. Multiple logistic regression analysis indicated that both literal homelessness and unstable housing were associated with less access to Medicaid and food stamps. Other significant findings were: current drug/alcohol-user treatment experience was associated with greater access to both Medicaid and food stamps, frequency of drug/heavy alcohol use was associated with less access to Medicaid only, and caring for children was associated with greater access to food stamps only. These findings support the crucial role of housing status in mediating access to entitlements, and the importance of drug/alcohol-user treatment involvement as a cue to seeking entitlements. The need to reduce health disparities through active and sustained outreach programs designed to enhance homeless persons' access to Medicaid and food stamp programs was discussed.     

Comparing homeless and domiciled pregnant substance dependent women on psychosocial characteristics and treatment outcomes

The present study compared pregnant drug-dependent women reporting homelessness (n=117) or being domiciled (n=118) at treatment enrollment on initial psychosocial functioning and subsequent drug treatment outcome. Homeless pregnant women presented with greater drug use and medical problems, less social service income, and more family/social difficulties than domiciled women. Homeless women had greater rates of psychiatric problems including suicidality and higher rates of physical, emotional and sexual abuse than their domiciled counterparts. Treatment retention was poorer for homeless than domiciled pregnant women. Results suggest that treatment should address the housing needs of pregnant drug abusers as well as their related social and psychiatric problems.     

Effective Services for Homeless Substance Abusers

A heterogeneous and representative sample of 323 homeless individuals in the metropolitan-Denver area with alcohol or other substance abuse problems received a comprehensive array of substance-abuse treatment services. Following treatment, these individuals showed dramatic improvement on average in their (a) levels of alcohol and drug use, (b) housing status, (c) physical and mental health, (d) employment, and (e) quality of life. Those who received more service improved more than those who received less service. These improvements are attributable, at least partly, to the treatment rather than to alternative hypotheses such as spontaneous remission. However, the rate of improvement generally slowed during the six-month follow-up period. A random half of the clients received intensive case management in addition to the other services. Case management marginally increased client's contacts with addiction counselors, but had little effect on the level of other services received or on the tailoring of services to client needs. As a result, case management also had little, if any, effect on outcomes.     

Engaging hospitalized heroin-dependent patients into substance abuse treatment.

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical center's medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.     

Homelessness,Substance Misuse,and Access to Public Entitlements in a Soup Kitchen Population

The study examined the effects of homelessness on access to public entitlements (Medicaid and food stamp programs) in a soup kitchen population. Data were collected between 1997 and 1999 from a sample of 343 adults at two soup kitchen sites in New York City. Five hypotheses, focusing on the effects of housing status (literal homelessness, unstable housing, and domiciled), frequency of drug/heavy alcohol use, drug/alcohol-user treatment history and childcare responsibilities on access to Medicaid and food stamp programs were tested. Multiple logistic regression analysis indicated that both literal homelessness and unstable housing were associated with less access to Medicaid and food stamps. Other significant findings were: current drug/alcohol-user treatment experience was associated with greater access to both Medicaid and food stamps, frequency of drug/heavy alcohol use was associated with less access to Medicaid only, and caring for children was associated with greater access to food stamps only. These findings support the crucial role of housing status in mediating access to entitlements, and the importance of drug/alcohol-user treatment involvement as a cue to seeking entitlements. The need to reduce health disparities through active and sustained outreach programs designed to enhance homeless persons’ access to Medicaid and food stamp programs was discussed.     

Health-related service utilization and HIV risk behaviors among HIV infected injection drug users and crack smokers.

This study was designed to assess utilization of health-related services and HIV risk related behaviors by HIV infected drug users one year prior to and two years following the availability of Ryan White Title I funding. Using a cross-sectional design, a total of 777 drug injectors and crack smokers from five US cities were surveyed, over three waves of data collection, about their use of drug treatment, medical services, housing, mental health, and case management and about their sex and drug-related risk behaviors. For all service categories and in each wave, including the year prior to Title I funding, HIV risk behaviors were lower among those who used health-related services, with the exception of housing. Use of services did not increase significantly following the disbursement of Title I funds except for housing and case management. These findings suggest that it may be necessary to increase the attractiveness of health-related services, not just funding for services, for HIV infected substance abusers.     

Using a “Big Events” framework to understand emergency department use among women experiencing homelessness or housing instability in San Francisco during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic created a major public health crisis that disrupted economic systems, social networks and individual behaviors, which led to changes in patterns of health care use. Factors associated with emergency department (ED) visits during the pandemic among especially high-risk individuals are unknown. We used a “Big Events” approach, which considers major disruptions that create social instability, to investigate ED use in people experiencing homelessness or housing instability, many of whom use drugs.MethodsBetween July and December 2020, we conducted a community-based San Francisco study to compare homeless and unstably housed (HUH) women who did and did not use an ED during the first 10 months of the pandemic.ResultsAmong 128 study participants, 34% had ≥1 ED visit during the pandemic. In adjusted analysis, factors significantly associated with ED use included experiencing homelessness, cocaine use and increased difficulties receiving drug use treatment during the pandemic.ConclusionThese findings build on the “Big Events” approach to considering risk pathways among people who use drugs. They suggest the importance of ensuring access to housing and low-barrier non-COVID health services, including drug treatment, alongside crisis management activities, to reduce the health impacts of public health crises.     

我中心药剂科应急药品管理模式的探索与实践

目的:为保障突发公共卫生事件发生时应急药品的供应提供参考。方法:分析我国应急药品储备的现状,探讨我中心药剂科应急药品管理模式建立的方法。结果与结论:我院药剂科通过健全管理制度和应急保障流程、加强科室人员的配备与管理培训、重视应急药品的储备和日常管理、强化信息支持等方法,建立了行之有效的应急药品管理模式。经过实战的考验,证明该模式能够有效地保障突发公共卫生事件中的应急药品供应。     

Recovery Housing: Evolving Models to Address Resident Needs

Recovery housing is a service delivery modality that simultaneously addresses the social support and housing needs of those in recovery from substance use disorders. This article describes a group of recovery homes in Texas (N = 10) representing a lesser-studied type of recovery housing, one which explicitly bridges treatment and peer support by providing a variety of recovery support services. All residents meet with a recovery coach, undergo regular drug screening, and have access to intensive outpatient treatment—a program that was developed specifically to support the needs of residents in the homes. Unlike the Oxford House^TM model and California sober living houses, which are primarily financed through resident fees, these homes are supported through a mix of resident fees as well as private and public insurance. While adhering to some aspects of the social model of recovery, none of these homes would meet criteria to be considered a true social model program, largely because residents have a limited role in the governance of the homes. Residences like the ones in this study are not well-represented in the literature and more research is needed.     

Drug consumption facility as part of a primary health care centre for problem drug users—Which clients are attracted?

BackgroundTo investigate whether users of a drug consumption facility (DCF) established as part of a health care centre for problem drug users fulfilled entry criteria, especially public drug consumption, risky drug-application and housing problems. We also investigated whether the drug consumption facility attracted hard-to-reach opiate users who usually do not use the health care system.MethodsStructured interviews were carried out with 129 problem drug users beginning attendance at a drug consumption facility.ResultsMedian length of the current episode of regular heroin use was 3 weeks. Sixty-seven per cent of clients had been in addiction specific treatment or had left prison during the previous 3 months. Regarding behaviour in the last month, 53% reported drug use in public, 53% use of non-sterile equipment or water, 22% needle sharing, 8% reported an emergency admission to hospital, and 43% were living in unstable accommodation. Only 10% of clients had never received treatment for their drug use and 87% were currently in contact with psychosocial services.ConclusionsThe majority of clients were chronic opiate users with high rates of risk behaviour. However, they did have recent contact with the drug treatment system. DCFs may be particularly important for opiate users after prison or treatment and/or for those with unstable accommodation.     

Health service utilisation attributable to methamphetamine use in Australia: Patterns,predictors and national impact

Aim and background. We estimated health service utilisation attributable to methamphetamine use, its national impact and examined other predictors of health service utilisation among dependent methamphetamine users. Method. Past year rates of health service utilisation (number of attendances for general hospitals, psychiatric hospitals, emergency departments, general practitioners, psychiatrists, counsellors or psychologists, and dentists) were estimated for three levels of methamphetamine use (no use, < weekly, ≥ weekly) using panel data from a longitudinal cohort of 484 dependent methamphetamine users from Sydney and Brisbane, Australia. Marginal rates for methamphetamine use were multiplied by 2013 prevalence estimates from the National Drug Strategy Household Survey. Covariates included other substance use, demographics, mental disorders and drug treatment. Findings. Health service use was high. More frequent methamphetamine use was associated with more frequent presentations to emergency departments (incidence rate ratios 1.3–2.1) and psychiatric hospitals (incidence rate ratios 5.3–8.3) and fewer presentations to general practitioners, dentists and counsellors. We estimate methamphetamine use accounted for between 28 400 and 80 900 additional psychiatric hospital admissions and 29 700 and 151 800 additional emergency department presentations in 2013. More frequent presentations to these services were also associated with alcohol and opioid use, comorbid mental health disorders, unemployment, unstable housing, attending drug treatment, low income and lower education. Conclusions. Frequent methamphetamine use has a significant impact on emergency medical and psychiatric services. Better provision of non‐acute health care services to address the multiple health and social needs of dependent methamphetamine users may reduce the burden on these acute care services. [McKetin R, Degenhardt L, Shanahan M, Baker AL, Lee NK, Lubman DI. Health service utilisation attributable to methamphetamine use in Australia: patterns, predictors and national impact. Drug Alcohol Rev 2017;00:000–000]     

Factors predicting unmet health services needs among incarcerated substance users

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998-1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed.     

Factors Predicting Unmet Health Services Needs Among Incarcerated Substance Users

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998–1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed.