Reprinted from the "Housing and Homelessness" issue of Visions Journal, 2007, 4 (1), pp. 9-10
For decades, researchers have been examining the dynamics of homelessness and substance use. While estimates of alcohol and drug use rates among the homeless vary considerably,1 there is agreement among experts that homeless people have much higher rates of substance use than the general population.2-4 At the same time, the number of people without adequate and secure housing among those who experience problems from substance use is high as well.5
One fact is clear: homeless individuals with alcohol, drug and mental disorders are among the most underprivileged and vulnerable groups in society.6-7 What is still up for debate, however, is whether substance use leads to homelessness, or homelessness leads to substance use.
It is easy for most of us to imagine how problem substance use could lead to homelessness. After all, if using alcohol or other drugs becomes more important than a person's work, health and relationships, it would logically follow that they might lose these important social and economic supports in their lives.
On the other hand, it is equally clear that becoming homeless could trigger a new substance use problem or worsen an existing one. A person might lean on alcohol or other drugs to help get through a tough night or face unpleasantness during the day - shame, fear, hunger and pain are just a few of the challenges a homeless person may experience.
Social selection: Substance use can lead to the streets
Most of the current evidence about the relationship between homelessness and substance use supports a social selection model. This model indicates that problem substance use may be a direct pathway to homelessness.
A number of studies provide support to this theory. Research reveals that approximately two-thirds of homeless people cite alcohol and/or other drugs as a major, and at times primary, reason for becoming homeless.4,8-9 In fact, many homeless people develop problems with alcohol and other drugs before losing their homes. One US study reports that, for people who have ever experienced homelessness, the median age (i.e., the mid-point across the participants' ages) at first street experience was 28 years. The median age at first symptoms of alcohol problems, however, was 22 years, and for drug problems, 25 years.10 Clearly, problem substance use is a significant risk factor that decreases a person's ability to respond to life's challenges.
Social causation: Street life increases substance use
There is also considerable evidence pointing to the social causation model. This model suggests that substance use increases as a very clear consequence of homelessness and serves as a method of coping with the stresses of street life. As early as 1946, researchers estimated that one-third of the homeless people in their investigation became heavy drinkers as a consequence of homelessness and related factors.10 In another example, from the UK, 80% of respondents revealed they had started using at least one new drug since living without a roof over their heads.8
There is nothing new about the idea that people on the street self-medicate to relieve life's stresses. After all, the non-homeless population also uses more alcohol and other drugs when they have trouble coping in their world.
Nor is it surprising to learn that alcohol consumption is key to acceptance in the homeless subculture, and thereby supports the causation theory. Our mainstream teen subculture, for instance, practises a similar kind of ritual.
Developing an integrated response to housing and treatment
Homelessness and substance use are complex issues. As our understanding of the relationship between them grows, it becomes increasingly evident that the question is not either/or, but rather, and. Our focus should be on seeking ways of addressing both issues simultaneously. It is critical that we do not let one problem lead to the other. This doubles the health care and social support costs11 and, more importantly, demoralizes an already disadvantaged population.12
Far too often, however, there has been a stronger emphasis on substance use and addictions treatment, than on providing other support services to substance users, including those who live on the street. Yet, research confirms that stable housing, both during and after treatment, is a key to successful treatment, because it decreases the risk of relapse.2,13
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It is also important to understand that as the pattern of substance use changes, so does the need for housing and supports. What is urgently needed, then, is the provision of safe and affordable housing with services that respond to each individual's unique needs. Furthermore, we should not only tackle homelessness and substance use, but should also help society's most vulnerable people boost their self-confidence and develop strong social networks.14
If housing, treatment and other social agencies work together toward developing a comprehensive response to the problems of homeless substance users, the whole community will benefit.
About the authorsEugenia and Nicole are both with the Centre for Addictions Research of BC, University of Victoria. Eugenia is a Research Assistant and Nicole is the Publications Officer.
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