Substance use among persons with homeless experience in primary care

ABSTRACT

Background: Community survey data suggest high prevalence of substance use disorders among currently homeless individuals. There are less data regarding illicit drug and alcohol use problems of homeless-experienced persons engaged in primary care. They may have less severe use and require different care responses from primary care teams. Methods: The authors surveyed currently and formerly homeless, i.e., homeless-experienced, persons engaged in primary care at five federally funded programs in the United States, administering the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST definitions of lower, moderate, and high risk were used to assess a spectrum of lifetime and recent substance use, from any use to likely dependence, and to identify sociodemographic and health status characteristics associated with severity of use. Results: Almost one half of the sample (N = 601) had recently (within the past three months) used alcohol, and one third had recently used an illicit drug. The most commonly used illicit drugs in the past three months were cannabis (19%), cocaine (16%), and opioids (7.5%). Over one half (59%) of respondents had ASSIST-defined moderate- or high-risk substance use. A significant proportion (31%) of those identified as at moderate risk had no recent substance use, but did report past problematic use. Ten percent of the lower-risk group had past problematic use of alcohol. Severity of use was associated with worse health status, but not with housing status or type of homelessness experienced. Conclusions: Less severe (moderate-risk) use and past problematic use, potentially indicative of remitted substance use disorders, were more common than high-risk use in this primary care, homeless-experienced sample. These findings highlight the urgency of identifying effective ways to reduce risky substance use and prevent relapse in homeless-experienced persons.

KEYWORDS:

• Homeless
• primary care
• substance use

Funding

The Department of Veterans Affairs Health Services Research & Development Branch (grant IAA-07-069-2) provided funding for the data collection on which this analysis is based. The Social Work Training in Addictions Research Institutional Predoctoral Fellowship (T32 DA015035) through the National Institute on Drug Abuse (NIDA) provided funding for the writing of the manuscript.

Although the authorship team has no commercial conflict of interest, most authors have past or present employment relationships with the entities studied in this paper (four VA health care centers and one Health Care for Homeless program). The Health Care for Homeless Program has employed authors Kertesz, Kim, and Stringfellow; the VA institutions have employed authors Austin, Gordon, Johnson, and Kertesz. Dr. Pollio received compensation for research services from the VA. Dr. Grucza has no affiliation with the institutions.

Author contributions

Ms. Stringfellow and Drs. Kim, Pollio, Gordon, and Kertesz contributed to research conception and design, data collection, analysis, and interpretation of the results as well as writing and revision of the manuscript. Ms. Johnson contributed to data collection and initial review of the manuscript. Drs. Grucza and Austin contributed to analysis of the results and in revisions of the manuscript.