Substance use disorders (SUDs) are illnesses that affect a person’s brain and behavior, leading to the inability to control the use of a legal or illegal drug or medication. The scope and effects of SUDs are complex, but there is no mistaking the impact that they have on the population. Research has established that a person’s access to safe, affordable housing affects their health outcomes. For individuals with SUD, access may be inhibited by pervasive stigma, punitive laws and policies, and lack of appropriate resources.
Lack of stable housing causes stress that often leads to poor health outcomes, especially for those suffering from SUDs. There is an overrepresentation of mental illness and substance use within urban populations experiencing homelessness, with estimates of the prevalence of SUDs between 29-75%. Punitive responses to and criminalization of the behaviors of people who use drugs remain a significant factor in the housing issues people with SUDs face. State and local policies and programs shape housing, but mostly national policies dictate what happens to people with SUDs and their family members. Federal laws mandate that public housing authorities and owners establish policies that allow for the eviction of entire households if as few as one member is using illicit drugs (read full list of criteria: here). Other laws target people with SUDs, making it difficult for them to find a home. A current bill, H.R. 2179: Drug Testing for Welfare Recipients, would require individuals to pass a drug test before eligibility for Section 8 rental assistance and public housing. Federal regulations allow housing authorities to consider drug use and convictions of people and/or their family members when making decisions to evict or deny access to federally subsidized housing. Stigma against individuals with SUDs displays its negative effects through policy both federally and locally.
Individuals with SUDs can access free market rentals with housing subsidies (e.g., the Housing Choice Voucher Program), but there is little research to document success or discrimination in response to their efforts. To solve this problem, we need to frame this discussion around the continuum of care for people with SUDs, primarily focusing on the different types of housing opportunities and services available. It’s important to begin with a differentiation of the types of recovery: (b) Aspirational/Harm Reduction recovery – abstinence is not the current goal, but the individual can visualize that as a goal as some future point. These individuals still wish to reduce harm associated with the use of substances and improve other aspects of their lives. There isn’t a “one size fits all” solution for those struggling with SUDs. Communities must ensure that their recovery housing programs accept and serve people at all stages of recovery, including those still using alcohol and drugs.
SUDs involving alcohol and illicit drugs are strongly associated with homelessness, with prevalence sometimes exceeding 50% in community samples. There have been many approaches to assisting individuals experiencing homelessness with co-occurring SUDs. Abstinence-oriented recovery homes, also called sober living houses (SLHs), are an option for persons with substance use problems hoping to abstain from substances on their program of recovery. SLHs are promoted as places to send clients to live after they complete residential treatment. SLHs are considered housing that fits in with single/multi-family neighborhoods and mixed-use residential-commercial areas. Recent research indicates that there have been favorable outcomes for individuals involved in this model, but there are significant limitations. One of the major limitations stems from the requirement for individuals to remain abstinent, which some people are unable to do. SLHs can provide a supportive environment for people in recovery, but as in traditional public housing, if residents can’t demonstrate their continued sobriety, they can be evicted. Meeting individuals where they are and working through their process is an important step in housing people with substance use problems.
Housing First uses a harm reduction approach, which focuses on reducing harm caused by the individual’s substance use and behavioral health issues. Immediate access to free or subsidized housing without requiring transitional steps or demonstrated sobriety is a main tenet of this philosophy. The United States Department of Housing and Urban Development (HUD) has begun to shift its approach to center around Housing First, as evidenced by its Continuum of Care (CoC) Program. There has been a demonstrated need for this low-demand approach, and the results have been promising. Reviews of the research on Housing First have indicated that when people experiencing homelessness are able to access free or subsidized apartments they are prone to stay in those locations for extended periods. Offering housing first and implementing case management services thereafter has spurred favorable outcomes for many individuals. Moreover, studies have demonstrated that people in the Housing First model with a serious mental illness, SUD, or co-occurring mental illness and SUD have demonstrated similar or better housing stability and recovery outcomes, compared to those placed in housing with pre-requisites like sobriety.
The stigma faced by those people with SUDs is manifested through policies that further exacerbate their situation and, in turn, detract from recovery. This issue is systemic and demands a multi-faceted response. If you work in a health center, providing information about Housing First opportunities in your community to patients is critically important. Each individual has their own set of needs, and providing these potential avenues of support can be vital in their recovery. It is equally important to advocate for the rights of people with SUDs. There are efforts that intersect with this issue, such as Rep. Alexandria Ocasio-Cortez’s and Sen. Kamala Harris’ collaboration to fight housing discrimination. Groups such as Treatment Communities of America (TCA) have created reports outlining the data and advocacy necessary to eliminate the lack of stable housing for those suffering with SUDs. Housing is health, and there are many ways to achieve positive health outcomes for those with substance use related issues. In order to ensure those outcomes, the individual’s needs must be emphasized in policy through harm reduction strategies that are not punitive and free of stigma.
Fewer than 2 symptoms = no disorder; 2-3 = mild disorder; 4-5 = moderate disorder; 6 or more = severe disorder.
Bianca Chun contributed to this post.