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Addiction Disorders and Homelessness
The relationship between homelessness and alcohol and drug addiction is
quite controversial. While addictive disorders appear disproportionately
among the homeless population, such disorders cannot, by themselves, explain
the increase in homelessness in the 1980s. Most drug and alcohol addicts
never become homeless. However, people who are poor and addicted are clearly
at increased risk. In the 1970s and 80s, competition for increasingly
scarce low-income housing grew so intense that those with disabilities
such as addictive and mental disorders were more likely to lose out and
find themselves on the streets.
PREVALENCE
Surveys of homeless populations conducted during the 1980s found consistently
high rates of addiction, particularly among single men. More recent studies,
however, have called the results of those studies into question. Briefly
put, the studies that produced high prevalence rates greatly over-represented
long-term shelter users and single men, and used lifetime rather than
current measures of addiction. There is no generally accepted "magic
number" with respect to the prevalence of addiction disorders among
homeless adults.
RELATIONSHIP TO HOMELESSNESS
In the past, single-room-occupancy (SRO) housing housed many poor individuals,
including poor persons suffering from addictive disorders and/or mental
illness. From 1970 to the mid-1980s, an estimated one million SRO units
were eliminated as a result of abandonment, gentrification, demolition,
and conversion (Wright and Rubin, 1997). The demolition of SRO housing
was most notable in large cities: between 1970 and 1982, New York City
lost 87 percent of its $200-per-month-or-less SRO stock; Chicago experienced
the total elimination of cubicle hotels; and by 1985, Los Angeles had
lost more than half of its downtown SRO housing (Koegel et al, 1996).
From 1975 to 1988, San Francisco lost 43 percent of its stock of low-cost
residential hotels; from 1970 to 1986, Portland, Oregon lost 59 percent
of its residential hotels; and from 1971 to 1981, Denver lost 64 percent
of its SRO hotels. Thus, the destruction of SRO housing is a major factor
in the growth of homelessness, particularly among people suffering from
addictive disorders, in many cities.
Untreated
addictive disorders do contribute to homelessness. For those with below-living
wage incomes and just one-step away from homelessness, the onset or exacerbation
of an addictive disorder may provide just the catalyst to plunge them
into residential instability. And for people who are addicted and homeless,
the health condition may be prolonged by the very life circumstance in
which s/he finds her/himself. Alcohol and drug use may help meet immediate
needs by providing respite from otherwise stressful and sometimes violent
conditions, and thus distract from activities oriented toward stability.
For people with untreated co-occurring serious mental illness, the use
of alcohol and other drugs may serve as a form of self-medication. For
still others, a sense of hopelessness about the future allows them to
discount their addictive disorder. These explanations for addiction's
sway over some homeless people should not obscure another reality - that
many homeless persons with addictive disorders desire to overcome their
disease, but that the combination of the homeless condition itself and
a service system ill-equipped to respond to these circumstances essentially
bars their access to treatment services and recovery supports.
POLICY ISSUES
There are numerous barriers to treatment and recovery opportunities. Homeless
people typically do not have health insurance, including Medicaid. This
means that few homeless people with addictive disorder are able to find
the resources necessary to pay for their own treatment or health care.
In addition, there are extensive waiting lists for addiction treatment
in most states: the National Association of State Alcohol and Drug Abuse
Directors estimated that in 1997, over one million people were waiting
for treatment nationwide. Moreover, people who are not easy to contact,
such as homeless people, are often dropped from the lists.
Other
barriers to treatment include lack of transportation, lack of documentation,
lack of supportive services, and abstinence-only programming. The bulk
of addictive disorder treatment and recovery public policies and programs
focus on abstinence as the single goal for individuals participating in
programs and for the programs themselves, and in some cases forbids the
alternative programs. Absolute lifetime abstinence is not a reality for
the majority of people with addictive disorders; relapse is an expected
occurrence in the course of treatment of the disease. Thus, this singular
focus has served as a barrier to the establishment of relapse-tolerant
programs, which may be more appropriate in some cases. The abstinence-only
orientation also fails to recognize the other important outcomes from
individual participation in addictive disorder treatment, including improved
overall physical health.
Recent
SSI policy changes appear to have increased homelessness among impoverished
people suffering from addictive disorders. In March 1996, President Clinton
signed into law legislation (P.L. 104-121) that denies Supplemental Security
Income (SSI) and Social Security Disability Insurance (SSDI) disability
benefits and, by extension, access to Medicaid, to people whose addictions
are considered to be a "contributing factor material to" the
determination of their disability status. Thus far, an estimated 103,000
disabled individuals have lost their SSI or SSDI as a result of this legislation.
SSI and SSDI benefits are often the only income that stands between an
individual and homelessness. Furthermore, they provide access to health
care through Medicaid. Preliminary results from a national study to document
the effects of SSI eligibility changes for persons served by Health Care
for the Homeless projects confirms the suspicion that loss of SSI and
SSDI income is resulting in increased homelessness: of 681 homeless clients
interviewed, 3.2% had recently lost their SSI or SSDI because of an alcohol
or drug-related disability, and of those persons who had been paying for
their own housing prior to losing SSI/SSDI benefits, two-thirds lost their
housing because they could no longer pay for it (National Health Care
for the Homeless Council, 1997).
The
dominant ideas concerning addiction that have shaped public policy stand
in sharp contrast to the policies recommended by many researchers and
medical practitioners. While the dominant public policy approach to addictive
disorders has been punitive, the most widely recommended policies developed
from medical and public health perspectives focus on prevention and treatment.
This is true for housed as well as homeless populations. There has been
a great deal of research based on Federally funded demonstration grants
on how to respond to the needs of homeless persons suffering from addiction
(Oakely and Dennis, 1996). This research makes clear that housing stability
is essential for successful treatment and/or recovery. When combined with
supportive services, meaningful daily activity in the community (including
work), and access to therapy, appropriate housing can provide the framework
necessary to end homelessness for many individuals. Without a stable place
to live, recovery often remains out of reach. Regrettably, the discoveries
of the demonstrations have not been widely translated to services delivery.
Despite
the severity of the problem, there are currently no Federal programs that
target funds to services for homeless people who have addiction disorders.
The Substance Abuse Prevention and Treatment Block Grant, the main source
of federal substance abuse treatment funds, does not currently target
funds to homeless people. Furthermore, current programs mandated to meet
the health care needs of homeless people do not have the resources necessary
to address addictive disorders in a thorough manner (Cousineau, 1995).
A targeted funding stream devoted to providing services to homeless people
with addiction disorders would help this population overcome homelessness.
In addition to targeted services, homeless people with addiction disorders
need affordable housing, jobs that pay liveable wages, and health care
if they are to leave and remain off the streets.
ADDITIONAL RESOURCES
Bureau of Primary Health Care, Division of Programs for Special Populations.
Health Care for the Homeless Program Profiles: Final Report, 1995. Available,
free, from the National Clearinghouse for Primary Care Information, 2070
Chain Bridge Rd., Suite 450, Vienna, VA 22182; 800/400-2742; in Washington,
DC metro area: 703/902-1248.
Cousineau,
Michael. A Study of the Health Care for the Homeless Program: Final Report,
1995. Available from the National Clearinghouse for Primary Care Information,
2070 Chain Bridge Rd., Suite 450, Vienna,VA 22182; 1-800-400-BPHC, ext.
248.
Dolbeare,
Cushing. "Housing Policy: A General Consideration," in Homelessness
in America, 1996, Oryx Press. Available for $43.50 from the National Coalition
for the Homeless, 1012 14th Street, NW, Washington, DC 20005; 202/737-6444.
Koegel,
Paul et al. "The Causes of Homelessness," in Homelessness in
America, Oryx Press, 1996. Available for $43.50 from the National Coalition
for the Homeless, 1012 14th Street, NW, Washington, DC 20005; 202/737-6444.
National
Coalition for the Homeless. Addiction on the Streets: Substance Abuse
and Homelessness in America, 1992. Available for $5.00 from the National
Coalition for the Homeless, 1012 14th Street, NW, Washington, DC 20005;
202/737-6444.
National
Coalition for the Homeless. No Open Door: Breaking the Lock on Addiction
Recovery for Homeless People, 1998. Available for $10.00 from the National
Coalition for the Homeless, 1012 14th Street, NW, Washington, DC 20005;
202/737-6444.
National
Health Care for the Homeless Council, Inc. SSI/SSDI Study, in Healing
Hands, Vol. 1, No. 6, 1997. Available from the National Health Care for
the Homeless Council, P.O. Box 60427, Nashville, TN 37206-0427; 615/226-2292.
Oakely,
Deirdre and Deborah L. Dennis, "Responding to the Needs of Homeless
People with Alcohol, Drug, and/or Mental Disorders," in Homelessness
in America, Oryx Press, 1996. Available for $43.50 from the National Coalition
for the Homeless, 1012 14th Street, NW, Washington, DC 20005; 202/737-6444.
Wright,
James and Beth Rubin. "Is Homelessness a Housing Problem?" in
Understanding Homelessness: New Policy and Research Perspectives, 1997.
Available, free, from the Fannie Mae Foundation, 4000 Wisconsin Avenue,
NW, North Tower, Suite One, Washington, DC 20016-2804; 202-274-8074 or
email: fmfpubs@fanniemaefoundation.org.
Last
updated - April 1999 - National Coalition for the Homeless
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