ࡱ > e h ` a b c d bjbj * r r dt ) R D D $ $ $ $ H H H P ! $ H ~ @" > ~- ( - - - 2 F J8 4 ~: ~ ~ ~ ~ ~ ~ ~ $ c &~ $ ; j1 2 ; ; &~ D D - - ;~ XA XA XA ; D - $ - Xs
XA ; ~ XA XA g @ l - K<= D> Hk 4 Ds Q~ 0 ~ |k V? h l l 8 $ Tl ; ; XA ; ; ; ; ; &~ &~ XA ; ; ; ~ ; ; ; ; ; ; ; ; ; ; ; ; ;
:
ABSTRACT
The magnitude of opioid abuse has reached epidemic levels as national survey data reveal that 4.5 million people across the country abuse medications intended for pain relief. Especially hard hit, all counties of southwestern Pennsylvania exceed the states mortality rate for deaths due to prescription drugs. The co-occurrence of substance abuse and homelessness has already been well established. As the homeless population of Allegheny County has increased, research that indicates drug overdoses have replaced HIV/AIDS as the leading cause of mortality among the homeless, with 80% of drug overdose deaths attributable to opioids, warrants concern. This article presents a review of treatment options for the homeless population with opioid use disorder which may be feasible to offer before securing housing, based upon recently published literature.
A search of PubMed was conducted. It was restricted to English-language articles with human subjects published between 2011 and 2015 that address therapies for opioid related disorders among the homeless. The term opioid related disorders as a MeSH Major Topic yielded 2,620 publications. The addition of the term therapy as a MeSH Subheading restricted the list to 1,901 publications. Further applying homeless as a term to be searched in all fields produced the final list of 15 publications. Review of these articles for relevance to the stated topic produced three publications for consideration.
Lessons gained from these programs demonstrate the importance of designing a public health approach to offer treatment for opioid abuse to the homeless, including the use of unconventional treatment sites, offering medication assisted treatment (MAT) and utilizing a harm reduction approach to establish housing. As the number of programs available and referral and utilization of the programs increase, special consideration should also be given to sources of funding. While the design of this review captures only three studies, future research should continue to examine social ecological influences on homelessness and opioid abuse to identify feasible interventions. Healthcare stakeholders must consider the importance of complex social ecological factors when determining how to address this epidemic and its immense financial and humanistic costs.
TABLE OF CONTENTS
TOC \o "2-4" \h \z \t "Heading 1,1,Appendix,1,Heading,1" HYPERLINK \l "_Toc438590611" preface PAGEREF _Toc438590611 \h ix
HYPERLINK \l "_Toc438590612" 1.0 Introduction PAGEREF _Toc438590612 \h 1
HYPERLINK \l "_Toc438590613" 1.1 Homelessness and Substance Abuse PAGEREF _Toc438590613 \h 2
HYPERLINK \l "_Toc438590614" 1.2 Opioid pharmacology and Addiction PAGEREF _Toc438590614 \h 4
HYPERLINK \l "_Toc438590615" 1.3 Medication-Assisted Treatment PAGEREF _Toc438590615 \h 5
HYPERLINK \l "_Toc438590616" 2.0 Methods PAGEREF _Toc438590616 \h 7
HYPERLINK \l "_Toc438590617" 3.0 Results PAGEREF _Toc438590617 \h 9
HYPERLINK \l "_Toc438590618" 3.1 The Mobile Medication Unit PAGEREF _Toc438590618 \h 10
HYPERLINK \l "_Toc438590619" 3.2 A Community-Based Recovery Center PAGEREF _Toc438590619 \h 12
HYPERLINK \l "_Toc438590620" 3.3 The Needle Exchange Program PAGEREF _Toc438590620 \h 14
HYPERLINK \l "_Toc438590621" 4.0 Discussion PAGEREF _Toc438590621 \h 15
HYPERLINK \l "_Toc438590622" 4.1 Unconventional Treatment sites PAGEREF _Toc438590622 \h 15
HYPERLINK \l "_Toc438590623" 4.2 Provision of mat PAGEREF _Toc438590623 \h 16
HYPERLINK \l "_Toc438590624" 4.3 harm reduction approach to housing PAGEREF _Toc438590624 \h 16
HYPERLINK \l "_Toc438590625" 4.4 program Funding and expansion PAGEREF _Toc438590625 \h 18
HYPERLINK \l "_Toc438590626" 5.0 conclusion PAGEREF _Toc438590626 \h 20
HYPERLINK \l "_Toc438590627" APPENDIX a: Example resources in allegheny county PAGEREF _Toc438590627 \h 23
HYPERLINK \l "_Toc438590628" bibliography PAGEREF _Toc438590628 \h 25
List of tables
TOC \h \z \c "Table" HYPERLINK \l "_Toc438587077" Table 1. Studies reporting treatment strategies for opioid abuse amongst the homeless PAGEREF _Toc438587077 \h 9
List of figures
TOC \h \z \c "Figure" HYPERLINK \l "_Toc438587078" Figure 1. Flowchart of Selection of Peer-Reviewed Articles to Assess Recent (2011-2015) Research on Therapies for Opioid Related Disorders among the Homeless PAGEREF _Toc438587078 \h 8
preface
The author would like to acknowledge the following individuals for their contributions to and mentorship during the development of the research described in this essay:
From the University of Pittsburgh Graduate School of Public Health: Martha Terry, PhD
From Allegheny General Hospital: Mary Lou Krieger, ACSW, LCSW; Laura Mark, MS, PharmD, FASHP; Arvind Venkat, MD
Introduction
The 2014 National Survey on Drug Use and Health identified that among the estimated 6.5 million people nationwide who use prescription drugs illicitly, 4.5 million, or 70%, are abusing pain relievers ADDIN EN.CITE Substance Abuse and Mental Health Services Administration201429(Substance Abuse and Mental Health Services Administration, 2014)292927Substance Abuse and Mental Health Services Administration,Rockville, MDSubstance use and mental health estimates from the 2013 national survey on drug use and health: overview of findings20149/4/2014( HYPERLINK \l "_ENREF_36" \o "Substance Abuse and Mental Health Services Administration, 2014 #29" Substance Abuse and Mental Health Services Administration, 2014). While abuse does not always develop into addiction, inappropriate use of prescription opioids carries substantial risks for opioid-related fatalities ADDIN EN.CITE Cheatle2015120(Cheatle, 2015)12012017Cheatle, M. D.Center for Studies of Addiction, Department of Psychiatry, Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.Prescription opioid misuse, abuse, morbidity, and mortality: Balancing effective pain management and safetyPain MedPain medicine (Malden, Mass.)Pain MedPain medicine (Malden, Mass.)Pain MedPain medicine (Malden, Mass.)S3-816 Suppl 12015/09/122015Oct1526-4637 (Electronic)
1526-2375 (Linking)2636093110.1111/pme.12904NLMeng( HYPERLINK \l "_ENREF_10" \o "Cheatle, 2015 #120" Cheatle, 2015). Specifically in Pennsylvania, mortality related to overdoses increased from 2.7 in 1990 to 15.4 overdose deaths per thousand residents in 2011 ADDIN EN.CITE Programs201422(Pennsylvania Department of Drug and Alcohol Programs, 2014)222227Pennsylvania Department of Drug and Alcohol Programs,Pennsylvania Drug and Alcohol Annual Plan And Report 2014-20152014( HYPERLINK \l "_ENREF_30" \o "Pennsylvania Department of Drug and Alcohol Programs, 2014 #22" Pennsylvania Department of Drug and Alcohol Programs, 2014). Locally, 2011 data from Allegheny County (AC) indicated that 20.5 people per 100,000 residents died from drug overdoses, pointedly increased from 6.3 per 100,000 in 1990 ADDIN EN.CITE Crompton201426(Crompton, 2014)262612Crompton, JaniceOverdose deaths from prescription drug abuse skyrocketing in southwestern PennsylvaniaPittsburgh Post-GazettePittsburgh Post-Gazette2015November 212014January 23Pittsburgh, PAhttp://www.post-gazette.com/local/south/2014/01/23/Overdose-deaths-from-prescription-drug-abuse-skyrocketing-in-southwestern-Pennsylvania/stories/201401230018November 16, 2014( HYPERLINK \l "_ENREF_11" \o "Crompton, 2014 #26" Crompton, 2014). The Pittsburgh Post-Gazette identified prescription drug abuse as a particularly troubling in southwestern Pennsylvania, noting that all southwestern Pennsylvania counties exceed death rates across the rest of the state ADDIN EN.CITE Crompton201426(Crompton, 2014)262612Crompton, JaniceOverdose deaths from prescription drug abuse skyrocketing in southwestern PennsylvaniaPittsburgh Post-GazettePittsburgh Post-Gazette2015November 212014January 23Pittsburgh, PAhttp://www.post-gazette.com/local/south/2014/01/23/Overdose-deaths-from-prescription-drug-abuse-skyrocketing-in-southwestern-Pennsylvania/stories/201401230018November 16, 2014( HYPERLINK \l "_ENREF_11" \o "Crompton, 2014 #26" Crompton, 2014).
Harrisburg, capital of the Commonwealth of Pennsylvania, also took notice of the epidemic. The 2014 report by the Pennsylvania Department of Drug and Alcohol Programs indicated that nearly 16% of the states budget, roughly $430 per capita, was spent on untreated or undertreated alcohol and substance abuse problems. Recognizing the need for action, on October 27, 2014, Pennsylvania Governor Tom Corbett enacted the Achieving Better Care by Monitoring All Prescriptions Act (ABC-MAP) of 2014. The ABC-MAP Act was designed to provide enhanced prescription drug monitoring in order to curb fraud and abuse. Among its many supporters, the Pennsylvania Medical Society hailed the law for its potential to help prescribers and dispensers (i.e. pharmacies) detect and stop doctor shoppers ADDIN EN.CITE Society201428(Pennsylvania Medical Society, 2014)282812Pennsylvania Medical Society,Prescription drug database soon a reality for PA physicians2014November 162014October 27http://www.pamedsoc.org/MainMenuCategories/Laws-Politics/News-from-Harrisburg/Legislation-News/CSDB.html11/16/2014( HYPERLINK \l "_ENREF_32" \o "Pennsylvania Medical Society, 2014 #28" Pennsylvania Medical Society, 2014). The law was not so warmly received by all, however. Echoing previous statements by the Office of National Drug Control Policy (2014), Andy Hoover, Legislative Director American Civil Liberties Union of Pennsylvania, identified this as only part of the solution. While solutions may include legal and regulatory action, it is time to put more investment into treatment and start addressing this as a public health issue ADDIN EN.CITE Amtissal201427(Amtissal, 2014)272712AmtissalNew prescription drug database signed into law2015July 122014October 27Fox 43 WPMThttp://fox43.com/2014/10/27/new-prescription-drug-database-signed-into-law/October 14( HYPERLINK \l "_ENREF_3" \o "Amtissal, 2014 #27" Amtissal, 2014).
Homelessness and Substance Abuse
Addressing an epidemic of opioid abuse warrants special consideration of social ecological factors for distinct populations, particularly those already disenfranchised, such as the homeless. Research by Galea and Vlahov (2002) described how social factors, including socioeconomic status and homelessness, are intertwined with drug use. The unsettling reality is that between 2010 and 2014, AC witnessed a 25% increase in the homeless population from 1,265 to 1,573 people, as measured by the annual Point-in-Time survey required by the United States Department of Housing and Urban Development ADDIN EN.CITE 201577(Allegheny County Department of Human Services, 2015)777727Allegheny County Department of Human Services,Data Brief: Allegheny CountyPoint-in-Time Homelessness Data, 2010 through 201420152/2015Allegheny County Department of Human Serviceshttp://www.alleghenycounty.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=2147493433( HYPERLINK \l "_ENREF_1" \o "Allegheny County Department of Human Services, 2015 #77" Allegheny County Department of Human Services, 2015). While the prevalence of individuals with severe mental illness accounted for the largest subpopulation of the homeless (approximately 40%), the second most prevalent subpopulation was individuals with chronic substance abuse (approximately 30%).
A recent study in Boston demonstrates cause for concern about substance abuse among Pittsburghs homeless and reason to approach it as a public health matter. ADDIN EN.CITE Baggett201380Baggett et al. (2013)808017Baggett, T. P.Hwang, S. W.OConnell, J. J.Porneala, B.C.Stringfellow, E.J.Orav, E.J.Singer, D.E.Rigotti, N.A.Mortality among homeless adults in boston: Shifts in causes of death over a 15-year periodJAMA Internal MedicineJAMA Intern MedJAMA internal medicine189-195173320132168-6106http://dx.doi.org/10.1001/jamainternmed.2013.160410.1001/jamainternmed.2013.1604 HYPERLINK \l "_ENREF_5" \o "Baggett, 2013 #80" Baggett et al. (2013) discovered a concerning shift in cause-specific mortality that developed over a 15 year time period within the homeless population. On the surface, all-cause mortality rates remained unchanged between 1988-1993 and 2003-2008 cohorts of homeless individuals. Increases in death due to drug overdose, however, were significant enough to make it the leading cause of death, and also offset decreases in HIV/AIDS mortality such that the net effect on all-cause mortality between cohorts was neutral. Notably, Baggett et al. (2013) found that 80% of overdose deaths were attributable to opioids. Reexamining their data from the 2003-2008 cohort of 28,000 homeless individuals, ADDIN EN.CITE ADDIN EN.CITE.DATA HYPERLINK \l "_ENREF_4" \o "Baggett, 2015 #121" Baggett et al. (2015) reported that drug-attributable mortality was 8 to 17 times greater in homeless women and 10 to 14 times greater in homeless men compared to the rest of the population.
Addressing either homelessness or substance abuse is independently complicated; the combination of the two, however, truly represents a difficult situation. Choosing which issue to address first presents a logistical challenge; whether it is more feasible to provide treatment for substance abuse while someone remains homeless or to provide housing to someone with known, ongoing substance abuse. For some time, the solution has been to provide housing assistance conditional upon demonstrated and maintained abstinence ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_20" \o "Henwood, 2014 #82" Henwood, Padgett, & Tiderington, 2014; HYPERLINK \l "_ENREF_23" \o "Kertesz, 2009 #119" Kertesz, Crouch, Milby, Cusimano, & Schumacher, 2009). A substance-free environment may be conducive to achieving and maintaining an addiction-free life for some of the population; however, for many homeless, finding food and shelter is more essential than drug counseling ADDIN EN.CITE 200933(National Coalition for the Homeless, 2009)333327National Coalition for the Homeless,Substance abuse and homelessnessJuly2009Washington, DCNational Coalition for the Homelesshttp://www.nationalhomeless.org/factsheets/addiction.html07/16/2015( HYPERLINK \l "_ENREF_28" \o "National Coalition for the Homeless, 2009 #33" National Coalition for the Homeless, 2009).
The housing debate is far from over, however. Interviews with front-line providers illustrate that strategies and treatment programs accepting of and prepared to address relapse as a harm reduction strategy are more effective than abstinence-only programming ADDIN EN.CITE Henwood201482(Henwood et al., 2014)828217Henwood, Benjamin F.Padgett, Deborah K.Tiderington, EmmyProvider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adultsThe Journal of Behavioral Health Services & ResearchThe journal of behavioral health services & research1241120141094-3412
1556-3308PMC3675178http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675178/10.1007/s11414-013-9318-2PMC( HYPERLINK \l "_ENREF_20" \o "Henwood, 2014 #82" Henwood et al., 2014). Housing First, a program developed by ADDIN EN.CITE Tsemberis2003132Tsemberis, Moran, Shinn, Asmussen, and Shern (2003)13213217Tsemberis, S.Moran, L.Shinn, M.Asmussen, S. M.Shern, D. L.Consumer preference programs for individuals who are homeless and have psychiatric disabilities: A drop-in center and a supported housing programAmerican Journal of Community PsychologyAmerican Journal of Community Psychology305-173232003http://search.proquest.com/docview/205347263?accountid=14709 HYPERLINK \l "_ENREF_40" \o "Tsemberis, 2003 #132" Tsemberis, Moran, Shinn, Asmussen, and Shern (2003) and further reported on by ADDIN EN.CITE Tsemberis2004131Tsemberis, Gulcur, and Nakae (2004)13113117Tsemberis, S.Gulcur, L.Nakae, M.The authors are with Pathways to Housing, Inc, New York, NY.Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual DiagnosisAm J Public HealthAmerican Journal of Public HealthAm J Public HealthAmerican journal of public healthAm J Public HealthAmerican journal of public health651-69442004Apr0090-0036 (Print)
1541-0048 (Electronic)15054020 HYPERLINK \l "_ENREF_39" \o "Tsemberis, 2004 #131" Tsemberis, Gulcur, and Nakae (2004) provides housing to those with mental health or substance abuse conditions without prerequisites for treatment or sobriety. Their findings suggest people for whom housing is provided immediately, without requirements for abstinence, are equally able to obtain and maintain that housing.
Opioid pharmacology and Addiction
Addressing a public health problem such as the opioid epidemic also requires awareness of individual-level risk factors. Understanding the effect prescription and illicit opioids have on neurologic processes provides useful insight on both the development and treatment of addiction. A variety of neurotransmitters has been implicated in the development of addiction, including serotonergic, opioid, endocannabinoid, GABAergic, and glutamatergic mechanisms ADDIN EN.CITE Gardner201168(Gardner, 2011)686817Gardner, E. L.Neuropsychopharmacology Section, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD 21224, USA. egardner@intra.nida.nih.govAddiction and brain reward and antireward pathwaysAdv Psychosom MedAdvances in psychosomatic medicineAdv Psychosom MedAdvances in psychosomatic medicineAdv Psychosom MedAdvances in psychosomatic medicine22-6030Behavior, Addictive/drug therapy/*physiopathology/psychologyBrain/*drug effectsHumansNarcotic Antagonists/therapeutic useNeural Pathways*RewardSubstance-Related Disorders/drug therapy/*physiopathology/psychology20110065-3268 (Print)
0065-3268 (Linking)21508625http://www.ncbi.nlm.nih.gov/pubmed/21508625454907010.1159/000324065( HYPERLINK \l "_ENREF_16" \o "Gardner, 2011 #68" Gardner, 2011). The most directly responsible neurotransmitter is dopamine, levels of which are increased in even simple pleasurable experiences. While research is still seeking to understand the exact mechanisms of opioid addiction, scientific literature widely supports the association between addictive drugs and activation of a common dopamine reward pathway ADDIN EN.CITE Furst201367(Furst, Riba, & Al-Khrasani, 2013)676717Furst, SusannaRiba, PalAl-Khrasani, MahmoudNew approach to the neurobiological mechanisms of addictionNeuropsychopharmacol HungNeuropsychopharmacol Hung189-205154201312/2013http://www.mppt.hu/folyoirat/1/abstract/?vol=15&issue=4&elsooldal=18911/21/2015( HYPERLINK \l "_ENREF_15" \o "Furst, 2013 #67" Furst, Riba, & Al-Khrasani, 2013).
The connection between addictive pharmacologic opioids and the dopamine reward pathway is understandable; the human body produces natural or endogenous opioids, commonly involved in pain perception, reward, stress and autonomic control ADDIN EN.CITE Benarroch201272(Benarroch, 2012)727217Benarroch, Eduardo E.Endogenous opioid systems: Current concepts and clinical correlationsNeurologyNeurology807-8147982012August 2110.1212/WNL.0b013e3182662098( HYPERLINK \l "_ENREF_6" \o "Benarroch, 2012 #72" Benarroch, 2012). Out of the opioid receptor subtypes, stimulation of the mu and delta receptors facilitates the release of dopamine. The central nervous system responds to repeated mu opioid receptor activation and consequential floods of dopamine with desensitization and adaptive tolerance. The body may develop tolerance to a variety of non-addictive substances. Tolerance for addictive substances becomes problematic however as the user requires increasingly greater doses to achieve the desired pain relief or pleasure. Further use may lead to dependence, characterized as the experience of withdrawal if the drug use is ceased ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_14" \o "Feng, 2012 #62" Feng et al., 2012; HYPERLINK \l "_ENREF_16" \o "Gardner, 2011 #68" Gardner, 2011). At the point that the individual exhibits a cluster of cognitive, behavioral and physiological symptoms and continues to use the substance despite significant substance-related problems, he or she has likely developed a substance use disorder ADDIN EN.CITE American Psychiatric Association201375(American Psychiatric Association, 2013)75755American Psychiatric Association,Substance Use DisorderDiagnostic and statistical manual of mental disorders5th ed2013Washington, DC( HYPERLINK \l "_ENREF_2" \o "American Psychiatric Association, 2013 #75" American Psychiatric Association, 2013).
Medication-Assisted Treatment
A joint effort between clinicians and the Federal government, Adapting Your Practice: Recommendations for the Care of Homeless Patients with Opioid Use Disorders, recommends the medication-assisted treatment (MAT) be offered to any patient with an opioid use disorder ADDIN EN.CITE Meges201438(Meges et al., 2014)383813Meges, DanielZevin, BarryCookson, ElizabethBascelli, LyndaDenning, PatLittle, JeannieDoe-Simkins, MayaWheeler, ElizaPhillips, S WatlovBhalla, PNance, MCobb, GTankanow, TWilliamson, JNational Health Care for the Homeless Council, Inc.Adapting your practice: Recommendations for the care of homeless patients with opioid use disorders1022014NashvilleHealth Care for the Homeless Clinicians' Network( HYPERLINK \l "_ENREF_27" \o "Meges, 2014 #38" Meges et al., 2014). Buprenorphine and methadone are the two most common medications used in MAT for substance use disorders. Methadone, a synthetically derived opioid, acts as a receptor agonist in that it stimulates the opioid receptors much like prescription opioid analgesics and heroin ADDIN EN.CITE Roxane Laboratories201570(Roxane Laboratories, 2015)707024Roxane Laboratories, Inc,Methadone solution: Highlights of prescribing information2015AprilColumbus, OH( HYPERLINK \l "_ENREF_35" \o "Roxane Laboratories, 2015 #70" Roxane Laboratories, 2015). When given in sufficient doses once daily, the long lasting effects of methadone make it possible to attenuate withdrawal and cravings associated with substance use disorder. A highly regulated Schedule II substance, the prescription of methadone for treatment of opioid addiction is subject to stringent Federal regulations ADDIN EN.CITE 201561(Substance Abuse and Mental Health Services Administration, 2015)616146Substance Abuse and Mental Health Services Administration,Substance Abuse and Mental Health Services Administration.Federal Guidelines for Opioid Treatment Programs822015Rockville, MDSubstance Abuse and Mental Health Services AdministrationHHS Publication No. (SMA) PEP15-FEDGUIDEOTPSubstance Abuse and Mental Health Services AdministrationAugust 3, 2015( HYPERLINK \l "_ENREF_37" \o "Substance Abuse and Mental Health Services Administration, 2015 #61" Substance Abuse and Mental Health Services Administration, 2015). State governmental agencies may also impose additional requirements for its prescribing and dispensing.
Buprenorphine behaves similarly to methadone; however while methadone is a full mu opioid agonist, buprenorphine is a partial agonist ADDIN EN.CITE Inc.201586(Indivior, 2015)868624Indivior, Inc.Suboxone: Highlights of prescribing information2015September 2015Richmond, VA2002http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=8a5edcf9-828c-4f97-b671-268ab13a8ecd10/22/2015( HYPERLINK \l "_ENREF_22" \o "Indivior, 2015 #86" Indivior, 2015). Like methadone, it is also generally given once a day. Buprenorphine will not activate the mu opioid receptors to the same degree as methadone and thus buprenorphine may be less appropriate for patients with high levels of opioid dependence and tolerance ADDIN EN.CITE Whelan201287(Whelan & Remski, 2012)878717Whelan, Paul J.Remski, KimberlyBuprenorphine vs methadone treatment: A review of evidence in both developed and developing worldsJournal of Neurosciences in Rural PracticeJournal of Neurosciences in Rural Practice45-50312012Jan-AprIndiaMedknow Publications & Media Pvt Ltd0976-3147
0976-3155PMC3271614http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271614/10.4103/0976-3147.91934PMC( HYPERLINK \l "_ENREF_41" \o "Whelan, 2012 #87" Whelan & Remski, 2012). Potential for abuse of buprenorphine is decreased by combining it with the opioid reversal agent naloxone. When taken orally as instructed, the naloxone has low bioavailability and will not affect the individual. If, however, an individual attempts to abuse the combined buprenorphine and naloxone product by way of dissolving and injecting it, the naloxone will trigger an antagonistic effect, producing withdrawal symptoms. Listed as a Schedule III substance, buprenorphine is also highly regulated by federal and state agencies.
Despite the best efforts of public health interventionists, there may be a variety of reasons why a community cannot or will not support the Housing First model ADDIN EN.CITE Didenko200744(Didenko & Pankratz, 2007)444417Eugenia DidenkoNicole PankratzSubstance Use: Pathways to homelessness? Or a way of adapting to street life?VisionsVisions9-10412007Summer 20071490-2494http://www.heretohelp.bc.ca/visions/housing-and-homelessness-vol47/20/2015( HYPERLINK \l "_ENREF_12" \o "Didenko, 2007 #44" Didenko & Pankratz, 2007). Bearing in mind the importance of patient-centered care, from a public health program planning perspective, successful interventions will offer flexible services that can adapt to the needs of individuals in AC, and the AC community itself. This paper presents a review of treatment options for the homeless population with opioid use disorder which may be feasible to offer before securing housing, based upon recently published literature.
Methods
The United States National Library of Medicines PubMed electronic database was accessed in October and November of 2015 using different combinations of Medical Subject Headings (MeSH) and subheading search terms. The search was restricted to English-language articles with human subjects published between 2011 and 2015 that address therapies for opioid related disorders among the homeless. The term opioid related disorders as a MeSH Major Topic yielded 2,620 publications. The addition of the term therapy as a MeSH Subheading restricted the list to 1,901 publications. Further applying homeless as a term to be searched in all fields produced the final list of 15 publications.
Inclusion criteria for these 15 publications required the article to address the homeless as the population target, as opposed to reported as a demographic with no further analysis; the article had to identify and describe the treatment as well as provide analysis of the outcomes as they related to reducing or eliminating substance use; the substances of abuse had to include opioids or heroin; and the article had to be available to access through the University of Pittsburgh Health Sciences Library System. Of these 15 articles, two were identified that met all inclusion criteria (Figure 1). One additional article was obtained and included as it was the foundation for one of the two articles identified through the PubMed search.
Figure SEQ Figure \* ARABIC 1. Flowchart of Selection of Peer-Reviewed Articles to Assess Recent (2011-2015) Research on Therapies for Opioid Related Disorders among the Homeless
Results
Each of the three final selected publications reported on a program that took place in a different state within the United States. Each used a unique modality for providing treatment services. None of the three was provided directly out of a methadone clinic or physicians office. A summary and comparison of the programs is presented in Table 1.
Table SEQ Table \* ARABIC 1. Studies reporting treatment strategies for opioid abuse amongst the homeless
FeatureHall, et al., 2014Daniels, et al., 2014Tringale, et al., 2015Target PopulationDisenfranchised individuals (e.g. homeless, injection drug users and uninsured)Clients of a community recovery center who were unsuccessful in recoveryTreatment-resistant poor, urban, heroin-dependent
needle exchange patientsInclusion CriteriaHousehold income at or below 350% of the Federal Poverty Level
Resident of New Jersey,
History of injection drug use,
Test positive for opioids,
Not currently enrolled in opioid replacement therapy
Uninsured.Opiate dependence (DSM-IV)Current heroin use
Needle exchange enrollmentExclusion CriteriaNone specifiedAlready receiving medication-assisted treatment for opioid dependencePositive methadone or benzodiazepine use
Heavy alcohol useLocationNew Jersey (6 sites)Baltimore, MDLos Angeles, CAStudy DesignProspective, CohortRetrospective, descriptiveProspective, descriptiveSettingMobile medication units, including a syringe exchange service
Brick and mortar methadone clinicsCommunity-based recovery center (Dees Place)Community-based needle exchange programFundingPublic funding
Blood borne Disease Harm Reduction Act of 2006Grant fundedGrant funded (NIH)Available TreatmentsBuprenorphine/naloxone or methadone
Detoxification
Diagnostic testing
Case management
Mental health services
Little to no charge to participantsBuprenorphine/naloxone
Daily meetings on recovery
Weekly (Friday) meetings on relapse prevention
Peer counselors
No charge to participantsBuprenorphine (22-day course, including 15 days of detoxification)
Peer support group
Substance-abuse counselors
Abstinence Testing or RequirementNoneTesting yes
Abstinence Requirement no Testing yes
Abstinence Requirement noRole of Homelessness in the StudyHomeless, injection drug users and uninsured were targeted populationsProgram sought to provide service to people who could/would not otherwise access
72% did not rent/own a home
18% living in transitional/recovery housingTargeted initiative of the Center for Harm Reduction of Homeless Healthcare Los AngelesAuthors Recommenda-tionsNeed to address connection between correctional/criminal justice system and substance abuse
Public funding addresses the barrier of affordability of treatment
Increase number of treatment facilities and improve geographic accessProviding buprenorphine services at community-based recovery center can help increase available treatment options
A community center-based buprenorphine program may hold promise for increasing access to and improving substance use outcomes among the most underserved.
Consider partnerships between Substance Abuse and Mental Health Services Agency and Accountable Care Organizations and the communities they serveComprehensive, non-judgmental detoxification and harm reduction reduces treatment-resistant needle exchange patients reluctance to enroll in long-term maintenance therapies.
Incorporate non-traditional settings into drug treatment as a way to enhance access to care and recovery for an underserved heroin-dependent populationThe Mobile Medication Unit
Hall and colleagues sought to understand the barriers to MAT experienced by the severely disenfranchised, including the homeless, uninsured and low-income populations by conducting a prospective cohort study ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_17" \o "Hall, 2014 #5" Hall et al., 2014). Through legislative action in the state of New Jersey, funding was provided for medication therapy (i.e. participants were offered the choice of either methadone or buprenorphine) and a mobile medication unit (MMU) that made two stops per day, six times per week, at six sites across the state. Each van was affiliated with a traditional office-based methadone clinic. Areas for visitation were identified based on their high prevalence of HIV and injection drug users (IDUs), homeless and uninsured. This community-based service was offered at little to no charge on a walk-in basis. The MMUs were equipped and staffed to also provide sterile syringe exchange, blood borne disease and STD testing, cognitive behavioral therapy, case management and connections to and financial support for other substance abuse treatment. Notably, case managers assisted participants with applying for Medicaid and provided counseling on employment and education opportunities. The MMU clients were compared to those who utilized methadone MAT via the traditional office-based methadone clinic as well as those who received treatment at the same location but did not receive MAT.
Based upon clients enrolled between 2008 and 2010, compared to participants receiving MAT from a traditional clinic, MMU clients were older, more likely to be African American or Latino, have less social capital (i.e. less likely to be married and more likely to be homeless or uninsured), more likely to be IDU and have a diagnosis of mental illness. The study also showed that of the 25% of clients that elected buprenorphine MAT, these clients were more likely to be African American, Latino and non-IDUs.
The recommendations of Hall et al. (2014) included increasing public funding to reduce barriers of affordability for treatment to the disenfranchised population, as well as to increase the number of available treatment facilities and geographic access. The MMU system was able to provide outreach to a population greatly in need of treatment an otherwise virtually unable to obtain it.
A Community-Based Recovery Center
Bringing the services to the population was also described in a retrospective, descriptive study by Daniels, Salisbury-Afshar, Hoffberg, Agus and Figerhood in 2014, conducted at a site in Baltimore, MD known as Dees Place. The aims of the study were to describe clients served by a buprenorphine program in a community-based recovery center and present initial treatment outcomes. The goal was to engage the recovery center population in treatment and once stable and insured, transition them to continued treatment in a primary care setting.
The unique feature of this program was the treatments colocation with the recovery center, which also hosted 12-Step meetings and connected participants with support services such as housing, legal assistance, health and mental health needs. In this case, the staff of Dees Place had approached the local nonprofit Behavioral Health Leadership Institute about providing treatment services at the center. While the primary goal of the center was not to provide treatment for opioid abuse, it nonetheless recognized that many people in the community were in need of services and would otherwise be unable to access them. On a weekly basis a team of a physician, nurses, counselors, a case manager and community outreach worker made contact with each participant at Dees Place. Prescriptions for up to a weeks take-home supply of buprenorphine/naloxone were paid for by grant funding and provided to participants free of charge.
Other features of the treatment program included daily to weekly contact with a nurse or case manager, urine drug screening, daily Narcotics Anonymous meetings as well as weekly relapse prevention meetings. While urine drug screens were monitored for the presence of buprenorphine and opiates, abstinence was not a requirement of continuation in the program; rather, the presence of opioids in the participants urine indicated to the clinical team that he or she needed additional support. For this reason, Dees Place provided recovery coaching through a team of counselors who have received additional training by the state-funded Baltimore Substance Abuse Services agency. Outcome measures included buprenorphine adherence and opiate abstinence. A successful participant obtained health insurance and established continued treatment with a community primary care provider.
Demographics from the Daniels, et al. (2014) study indicate that among the 78 individuals from that population who received treatment, 78% were African American and 55% were males. Approximately 72% did not own or rent their own home, 18% of whom were living in transitional or recovery housing. Overall, the average length of treatment for all clients was 13.5 weeks, during which the mean percent of opiate-abstinent weeks was 83% and buprenorphine-adherent weeks was 95%. Approximately half of all participants were successfully transitioned to primary care-based treatment, with no statistically significant differences between those who transitioned and those who did not. Successfully transitioned clients did, however, have a significantly longer time in treatment than those who did not, with respective means of 20.5 weeks versus 6.9 weeks.
Daniels, et al. (2014) arrived at the conclusion that treatment needs to be provided in the areas of need. Buprenorphine programs are less restrictive than those to operate a methadone clinic, thus may be a practical option to in these settings. Treatment services at a recovery center were able to access a marginalized group of people who were identified by their own community.
The Needle Exchange Program
Following publication of the Daniels, et al. (2014) study, a group of Los Angeles colleagues submitted a letter to the editor of the Journal of Addiction Medicine ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_38" \o "Tringale, 2015 #1" Tringale, Subica, Danielian, & Kaplan, 2015). A non-traditional drug treatment center, the Center for Harm Reduction of Homeless Healthcare Los Angeles sought to help treatment-resistant, poor, urban, heroin-dependent patients transition to opioid maintenance therapy as a harm reduction strategy. As a pilot study with nine patients, Tringale et al. sought to identify the potential for a program that appealed to this population based on its non-judgmental philosophy and acceptance of relapse, 15-day buprenorphine detoxification supported by peers and daily provider dispensed dosing and certified substance abuse counselors. Participants were identified through a local needle exchange program. Of note, patients who tested positive for benzodiazepine use were excluded from the study, due to risk of overdose.
Of the seven patients who completed the 22-day program, six were successfully transitioned to long-term MAT. Participants reported that the ability for buprenorphine to reduce cravings and stabilize cognition and emotional processing, permitted use of opiates and illicit substances and long-term treatment goal planning were strengths of the program. The investigators openly acknowledged the size of their study as a significant limitation.
Discussion
Many aspects of the three programs previously described are consistent with recommendations put forth by Health Care for the Homeless Clinicians Network (2014), developed with support from the Bureau of Primary Health Care, Health Resources and Services Administration and U.S. Department of Health and Human Services. This review presented several important themes to designing a public health approach to offer treatment for opioid abuse to the homeless, including the use of unconventional treatment sites, offering MAT and utilizing a harm reduction approach to establish housing. As part of the evaluation for any intervention, consideration is also given to funding of these programs.
Unconventional Treatment sites
The most salient feature of these three programs was their novel approach to providing treatment to a marginalized population through unconventional treatment sites. Both the Assistant Surgeon Generals 1999 report on Principles of Practice, A Clinical Resource Guide for Health Care for the Homeless ADDIN EN.CITE Administration199945(Health Resources and Services Administration, 1999)454527Health Resources and Services Administration,Department of Health and Human ServicesPrinciples of Practice: A Clinical Resource Guide for Health Care for the Homeless Programs1999March 1http://bphc.hrsa.gov/policiesregulations/policies/pal199912.pdfJuly 15, 2015( HYPERLINK \l "_ENREF_18" \o "Health Resources and Services Administration, 1999 #45" Health Resources and Services Administration, 1999) as well as the 2014 report from the Health Care for the Homeless Clinicians Network guide Adapting Your Practice: Recommendations for the Care of Homeless Patients with Opioid Use Disorders ADDIN EN.CITE Meges201438(Meges et al., 2014)383813Meges, DanielZevin, BarryCookson, ElizabethBascelli, LyndaDenning, PatLittle, JeannieDoe-Simkins, MayaWheeler, ElizaPhillips, S WatlovBhalla, PNance, MCobb, GTankanow, TWilliamson, JNational Health Care for the Homeless Council, Inc.Adapting your practice: Recommendations for the care of homeless patients with opioid use disorders1022014NashvilleHealth Care for the Homeless Clinicians' Network( HYPERLINK \l "_ENREF_27" \o "Meges, 2014 #38" Meges et al., 2014) support utilization of community-based models for the treatment of opioid addiction among the homeless. The programs featured here established treatment in areas where the homeless were known to be found and by doing so, each program found a way to bring services to people who otherwise did not have the resources to seek treatment or feel comfortable in a traditional office or clinic setting.
Provision of mat
All three programs included in this review also made use of MAT. This is consistent with guidelines developed by agencies of the federal and Pennsylvania government to guide clinicians and healthcare advocates to take on the opioid epidemic ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_24" \o "Mann, 2014 #35" Mann, Frieden, Hyde, Volkow, & Koob, 2014; HYPERLINK \l "_ENREF_27" \o "Meges, 2014 #38" Meges et al., 2014; HYPERLINK \l "_ENREF_30" \o "Pennsylvania Department of Drug and Alcohol Programs, 2014 #22" Pennsylvania Department of Drug and Alcohol Programs, 2014). All three of the programs described herein offered treatment with buprenorphine; only Hall et al. (2014) additionally offered methadone. Despite their lack of stable housing, the clinicians and research teams involved felt that under supervision and with evidence-based behavioral therapies, MAT is a safe and cost-effective manner of treating opioid and heroin substance use disorders.
harm reduction approach to housing
The third theme of these programs was taking a harm reduction approach to establishing housing for people seeking recovery. Doing so acknowledges the complexity and resources that must be involved to overcome homelessness and opioid abuse. While Daniels, et al. (2014) and Tringale, et al. (2015) incorporate drug screening as part of their protocols, relapse did not exclude people or result in dismissal from the program; rather, it was used to identify individuals who needed additional support.
This is important to consider when assessing treatment programs available to the homeless of western Pennsylvania. In AC alone there were over 1,500 homeless individuals (excluding those in permanent supportive housing), 93% of whom had access to shelter (i.e. a primary nighttime residence that is a supervised shelter designed to provide temporary living accommodations, including both emergency shelters and transitional housing) ADDIN EN.CITE Allegheny County Department of Human Services201577(Allegheny County Department of Human Services, 2015)777727Allegheny County Department of Human Services,Data Brief: Allegheny CountyPoint-in-Time Homelessness Data, 2010 through 201420152/2015Allegheny County Department of Human Serviceshttp://www.alleghenycounty.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=2147493433( HYPERLINK \l "_ENREF_1" \o "Allegheny County Department of Human Services, 2015 #77" Allegheny County Department of Human Services, 2015). While considered shelter, it is unclear whether these provide sufficient stability and security to foster recovery from opioid abuse. Furthermore, while AC has a capacity of approximately 1,000 beds in transitional or permanent supportive housing, for some, mandatory abstinence restricts access to initial or continued housing if a person should relapse ADDIN EN.CITE Burger201578(Burger, Horn, Bell, & Dalton, 2015; Familylinks, 2014)787827Burger, RyanHorn, AbigailBell, BrianDalton, ErinAllegheny County DHSOffice of Data Analysis, Research and EvaluationIndividuals Involved in the Allegheny County Homelessness System20158/2015Allegheny County Department of Human Serviceshttp://www.alleghenycounty.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=214749680011/5/2015Familylinks81818112FamilylinksPenn Free Bridge HousingNovember 102014http://familylinks.org/index.php/housing/penn-free( HYPERLINK \l "_ENREF_7" \o "Burger, 2015 #78" Burger, Horn, Bell, & Dalton, 2015; HYPERLINK \l "_ENREF_13" \o "Familylinks, 2014 #81" Familylinks, 2014). Therein lays the advantage of the three programs previously described: their ability to provide treatment despite the lack of stable housing.
As part of a preliminary assessment of services for the homeless in AC, focus groups with clients of the AC homelessness service system revealed that strict clean-time and background check requirements made it difficult to find a housing program ADDIN EN.CITE Horn201579(Horn, Whitehill, & Yonas, 2015)797927Horn, AbigailWhitehill, EvelynYonas, MichaelHomeless in Allegheny County - The client experience20151/2015Allegheny County Department of Human Services, Office of Data Analysis Research and Evaluationhttp://www.alleghenycounty.us/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=2147493434( HYPERLINK \l "_ENREF_21" \o "Horn, 2015 #79" Horn, Whitehill, & Yonas, 2015). The importance of changing this experience was supported by the Pennsylvania Department of Drug and Alcohol Programs in their 2014-2015 strategic plan, which outlined the need to expand access to and availability of resources to support homeless with substance use disorders ADDIN EN.CITE Pennsylvania Department of Drug and Alcohol Programs201422(Pennsylvania Department of Drug and Alcohol Programs, 2014)222227Pennsylvania Department of Drug and Alcohol Programs,Pennsylvania Drug and Alcohol Annual Plan And Report 2014-20152014( HYPERLINK \l "_ENREF_30" \o "Pennsylvania Department of Drug and Alcohol Programs, 2014 #22" Pennsylvania Department of Drug and Alcohol Programs, 2014). A number of agencies have also endorsed program guidelines that also services such as the management of concurrent physical and mental health issues as well as employment services ADDIN EN.CITE ADDIN EN.CITE.DATA ( HYPERLINK \l "_ENREF_24" \o "Mann, 2014 #35" Mann et al., 2014; HYPERLINK \l "_ENREF_28" \o "National Coalition for the Homeless, 2009 #33" National Coalition for the Homeless, 2009; HYPERLINK \l "_ENREF_29" \o "National Health Care for the Homeless Council, 2011 #43" National Health Care for the Homeless Council, 2011). This comprehensive approach addresses the complicating factors that make recovery from opioid abuse especially difficult for the homeless.
program Funding and expansion
Implementation of all three programs described by Hall et al. (2014), Daniels et al. (2014) and Tringale et al. (2015) was supported by public or grant funding. Identification of new funding streams will be critical for successful implementation of new programs or expansion of existing programs in AC, which may include receipt of federal grants. Encouraging statements by the federal government have suggested that several regulatory changes and funding opportunities are on the horizon. Health and Human Services Secretary Sylvia Burwell announced the agencys plans to revise Federal regulations in order to expand access to buprenorphine treatment as well as award $1.8 million in grants to support community partnerships, including facilitating referrals to substance abuse centers ADDIN EN.CITE Burwell201594(Burwell, 2015)949412Burwell, Sylvia Mathews50-State convening to prevent opioid overdose and addiction2015December 12015September 17Arlington, VADepartment of Health and Human Serviceshttp://www.hhs.gov/about/leadership/secretary/speeches/2015/50-state-convening-prevent-opioid-overdose-and-addiction.html( HYPERLINK \l "_ENREF_8" \o "Burwell, 2015 #94" Burwell, 2015). Previous research has presented a number of reasons why chronic heroin users put off seeking health care, which may contribute to inappropriate use of the emergency departments ADDIN EN.CITE McCoy200141(McCoy, Metsch, Chitwood, & Miles, 2001)414117McCoy, Clyde B.Metsch, Lisa R.Chitwood, Dale D.Miles, ChristineDrug use and barriers to use of health care servicesSubst Use MisuseSubst Use MisuseSubstance use & misuse789-8006366&72001( HYPERLINK \l "_ENREF_25" \o "McCoy, 2001 #41" McCoy, Metsch, Chitwood, & Miles, 2001). Hospitals and emergency departments therefore may be suitable environments to help identify individuals ready to accept treatment and connect them to community services ADDIN EN.CITE McNeil201592(McNeil, Kerr, Pauly, Wood, & Small, 2015)929217McNeil, R.Kerr, T.Pauly, B.Wood, E.Small, W.BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada.
Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columba, Canada.
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
School of Nursing, University of Victoria, Victoria, British Columbia, Canada.
Centre for Addictions Research of British Columbia, Victoria, British Columbia, Canada.Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitalsAddictionAddictionAddictionAddictionAddictionAddiction2015Oct 241360-0443 (Electronic)
0965-2140 (Linking)26498577http://www.ncbi.nlm.nih.gov/pubmed/2649857710.1111/add.13214( HYPERLINK \l "_ENREF_26" \o "McNeil, 2015 #92" McNeil, Kerr, Pauly, Wood, & Small, 2015).
With increasing numbers of programs and increasing referrals to programs, the demand for funding will consequentially increase. Financial support to provide MAT for the homeless will need included in any program proposal. Pennsylvanias Medicaid program presently covers both buprenorphine and methadone for those that are enrolled ADDIN EN.CITE Services201589(Pennsylvania Department of Human Services, 2015)898912Pennsylvania Department of Human Services,Preferred Drug List201511/30/201520157/20/2015http://www.providersynergies.com/services/documents/PAM_PDL.pdfProvider Synergies, LLC( HYPERLINK \l "_ENREF_31" \o "Pennsylvania Department of Human Services, 2015 #89" Pennsylvania Department of Human Services, 2015); however, not all homeless may be enrolled. Despite the efforts of the Affordable Care Act, data from the 2014 National Health Care for the Homeless Program suggest that 43.1% of homeless patients are uninsured; this may in fact an underestimate, as it was based solely on patients presenting to the Health Care for the Homeless programs ADDIN EN.CITE Administration201491(Health Resources and Services Administration, 2014)919145Health Resources and Services Administration,2014 National Health Care for the Homeless Program Grantee Data201412/1/2015http://bphc.hrsa.gov/uds/datacenter.aspx?q=t4&year=2014&state=&fd=ho( HYPERLINK \l "_ENREF_19" \o "Health Resources and Services Administration, 2014 #91" Health Resources and Services Administration, 2014).
Fortunately, AC already has a number of organizations to effect positive change in opioid abuse among the homeless in AC (Appendix A). At present, organizations such as Prevention Point Pittsburgh, Familylinks and Operation Safety Net are already operational and providing health interventions to the homeless. Leveraging their established relationships with the homeless community and expanding provision of MAT, possibly by developing novel outreach efforts like the three presented here, will be an essential part of the public health strategy for treating the opioid epidemic.
conclusion
The magnitude of opioid abuse has reached epidemic levels as national survey data reveal that 4.5 million people across the country abuse medications intended for pain relief. Especially hard hit, all counties of southwestern Pennsylvania exceed the states mortality rate for deaths due to prescription drugs. The co-occurrence of substance abuse and homelessness has already been well established. As the homeless population of AC has increased, research that indicates drug overdoses have replaced HIV/AIDS as the leading cause of mortality among the homeless, with 80% of overdose deaths attributable to opioids, warrants concern. This article presents a review of treatment options for the homeless population with opioid use disorder which may be feasible to offer before securing housing, based upon recently published literature.
A search of PubMed has produced three studies published in the last five years on unique programs. Lessons gained from these programs demonstrate the importance of designing a public health approach to offer treatment for opioid abuse to the homeless, including the use of unconventional treatment sites, offering MAT and utilizing a harm reduction approach to establish housing. As the number of programs available and referral and utilization of the programs increase, special consideration should also be given to sources of funding. While the design of this review captures only three studies, future research should continue to examine social ecological influences on homelessness and opioid abuse to identify feasible interventions. Healthcare stakeholders must consider the importance of complex social ecological factors when determining how to address this epidemic and its disturbing financial and humanistic costs.
The most prominent limitation of this review is the capture of only three publications in the last five years. This may be attributable to the search methodology described, as utilized in PubMed. While homelessness is often reported as a demographic factor, this review was dependent upon the term homeless as part of its search parameter. The review also targeted studies specifically aimed at the homeless. It is likely that a variety of other treatment strategies may be adaptable to this population, although they have not been published as being focused on the homeless. The search was also limited to English-only articles. Other indexed databases of research may also provide additional relevant articles.
Future investigation should continue to follow the social ecological model to identify successful methods of treatment, as this public health problem is far too large and complex to be solved at any one level alone. Directly involving peers of the homeless and recovered formerly homeless individuals in the design of interventions, as Daniels et al. (2014) and Tringale et al. (2015) did, would be beneficial as they can draw upon their own experiences and relationships with this community. The qualitative research by McNeil et al. (2015) demonstrates the insights that can be gained through semi-structured interviews in order to better understand the perspective of this population. Both of these approaches will help to develop feasible interventions that are culturally sensitive to the homeless population.
The potential financial and humanistic costs of healthcare stakeholders failing to respond to this epidemic are perhaps most unsettling. Prescription opioid abuse, dependence and misuse were estimated to have incurred societal costs estimated at $55.7 billion from 2003 to 2007 alone (Birnbaum et al., 2011). Left unaddressed, at current mortality rates, 44 people across the nation will continue to die on a daily basis due to opioid overdose ADDIN EN.CITE Centers for Disease Control and Prevention2015125(Centers for Disease Control and Prevention, 2015)12512512Centers for Disease Control and Prevention,Prescription drug overdose dataInjury Prevention and Control: Prescription Drug Overdose2015December 172015October 16http://www.cdc.gov/drugoverdose/data/overdose.html(Centers for Disease Control and Prevention, 2015 HYPERLINK \l "_ENREF_9" \o "Centers for Disease Control and Prevention, 2015 #125" Centers for Disease Control and Prevention, 2015). When developing interventions to address the epidemic, public health advocates and clinicians must remember that it will not be a model of one size fits all; rather, applying the social ecological model to understand complex factors and design community-oriented approaches will be critical to reigning in the costs of abuse and reaching even the most marginalized members of society.
Healthcare stakeholders must consider again the findings presented by Baggett et al. (2013), demonstrating that drug overdose, particularly related to opioid analgesics and heroin, has replaced HIV/AIDS as the leading cause of death of homeless adults. Advances in antiviral medicine have transformed HIV/AIDS from a deadly condition into a chronic disease state, making it possible for many, including the homeless, to live longer, healthier lives. Yet it seems cruelly ironic that substance abuse, including opioid medications, has now become their primary cause of mortality.
APPENDIX a: Example resources in allegheny county
Operation Safety Net
ADDIN EN.CITE Pittsburgh Mercy Health System12812812812Pittsburgh Mercy Health System,Operation Safety NetNovember 102015https://www.pmhs.org/operation-safety-net/Website: HYPERLINK "https://www.pmhs.org/operation-safety-net/" https://www.pmhs.org/operation-safety-net/
Purpose: As long as there are unsheltered homeless sleeping on our streets, in our abandoned buildings, and along our riverbanks, Operation Safety Net will provide access to health care that is designed to meet their unique needs. Program activities include:
Street Outreach: Walking teams of clinicians and formerly homeless workers provide care in the streets.
Case Management: Patients are given a supportive environment to help them plan their own recovery.
Computerized Database: OSN is a pioneer in applying information technology with health care treatment.
Medical Services Mobile Van: The van is a physician's office on wheels that travels to distressed areas afflicted by poverty, drugs and crime.
WellSpring Drop-in Clinic: Primary care services, free of charge, are provided in a physician office complex.
Medical Education: OSN trains future physicians and clinicians to provide care to the poor.
Projects: OSN builds community through public health partnerships, housing connections, research studies, and local as well as national leadership roles.
Prevention Point Pittsburgh ADDIN EN.CITE 201512712712712Prevention Point Pittsburgh2015November 102015www.pppgh.org
Website: HYPERLINK "http://www.pppgh.org/services" www.pppgh.org/services
Prevention Point Pittsburgh (PPP) is a nonprofit organization dedicated to providing health empowerment services to injection drug users.
In addition to needle exchange services, PPP has grown to include comprehensive case management services, assistance to drug treatment, individualized risk-reduction counseling, health education, condom and bleach distribution, overdose prevention with Narcan prescription, and free HIV, Hepatitis C, and syphilis screening in collaboration with the Allegheny County Health Department.
Familylinks
Website: HYPERLINK "http://www.familylinks.org" www.familylinks.org
Penn Free Bridge Housing: Penn Free Bridge Housing offers secure housing to people ages 18 and older who are homeless and in recovery from alcohol or drug abuse, who have been referred via Allegheny Link. The program provides:
Secure, financially-supported accommodations for individuals and/or families for up to one year
Supportive services in areas such as employment, education, counseling, legal issues, medical support and household needs
Bus tickets and passes as needed
Assurance of recovery program, including random urine tests
To qualify for admission to Penn Free Bridge Housing, individuals must be:
18 years or older
Earning less than 200% of the federal poverty guideline limit
Homeless by County definition and referred via the Allegheny Link housing list
Chemical-free for a minimum of 90 days
In treatment for substance abuse, or actively involved in recovery
Shelter Plus Care Program: Familylinks realizes that some people need support on an ongoing basis. Shelter Plus Care Program provides permanent housing and case management services for people and families that are homeless and have disabilities, including mental health issues and/or substance abuse.
Federally funded by the Department of Housing and Urban Development, Shelter Plus Care may subsidize up to 100% of rent, depending on an individual's income.
biblio ADDIN EN.CITE Familylinks201481818112FamilylinksPenn Free Bridge HousingNovember 102014http://familylinks.org/index.php/housing/penn-freegraphy
ADDIN EN.REFLIST Allegheny County Department of Human Services. (2015). Data Brief: Allegheny CountyPoint-in-Time Homelessness Data, 2010 through 2014: Allegheny County Department of Human Services.
American Psychiatric Association. (2013). Substance Use Disorder Diagnostic and statistical manual of mental disorders (5th ed ed.). Washington, DC.
Amtissal. (2014, October 27). New prescription drug database signed into law. Retrieved July 12, 2015, from HYPERLINK "http://fox43.com/2014/10/27/new-prescription-drug-database-signed-into-law/" http://fox43.com/2014/10/27/new-prescription-drug-database-signed-into-law/
Baggett, T. P., Chang, Y., Singer, D. E., Porneala, B. C., Gaeta, J. M., O'Connell, J. J., & Rigotti, N. A. (2015). Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health, 105(6), 1189-1197. doi: 10.2105/ajph.2014.302248
Baggett, T. P., Hwang, S. W., OConnell, J. J., Porneala, B. C., Stringfellow, E. J., Orav, E. J., . . . Rigotti, N. A. (2013). Mortality among homeless adults in boston: Shifts in causes of death over a 15-year period. JAMA Internal Medicine, 173(3), 189-195. doi: 10.1001/jamainternmed.2013.1604
Benarroch, E. E. (2012). Endogenous opioid systems: Current concepts and clinical correlations. Neurology, 79(8), 807-814. doi: 10.1212/WNL.0b013e3182662098
Burger, R., Horn, A., Bell, B., & Dalton, E. (2015). Individuals Involved in the Allegheny County Homelessness System (R. a. E. Office of Data Analysis, Trans.): Allegheny County Department of Human Services.
Burwell, S. M. (2015, September 17). 50-State convening to prevent opioid overdose and addiction. Retrieved December 1, 2015, from HYPERLINK "http://www.hhs.gov/about/leadership/secretary/speeches/2015/50-state-convening-prevent-opioid-overdose-and-addiction.html" http://www.hhs.gov/about/leadership/secretary/speeches/2015/50-state-convening-prevent-opioid-overdose-and-addiction.html
Centers for Disease Control and Prevention. (2015, October 16). Prescription drug overdose data. Injury Prevention and Control: Prescription Drug Overdose. Retrieved December 17, 2015, from HYPERLINK "http://www.cdc.gov/drugoverdose/data/overdose.html" http://www.cdc.gov/drugoverdose/data/overdose.html
Cheatle, M. D. (2015). Prescription opioid misuse, abuse, morbidity, and mortality: Balancing effective pain management and safety. Pain Med, 16 Suppl 1, S3-8. doi: 10.1111/pme.12904
Crompton, J. (2014, January 23). Overdose deaths from prescription drug abuse skyrocketing in southwestern Pennsylvania. Pittsburgh Post-Gazette. Retrieved November 21, 2015, from HYPERLINK "http://www.post-gazette.com/local/south/2014/01/23/Overdose-deaths-from-prescription-drug-abuse-skyrocketing-in-southwestern-Pennsylvania/stories/201401230018" http://www.post-gazette.com/local/south/2014/01/23/Overdose-deaths-from-prescription-drug-abuse-skyrocketing-in-southwestern-Pennsylvania/stories/201401230018
Didenko, E., & Pankratz, N. (2007). Substance Use: Pathways to homelessness? Or a way of adapting to street life? Visions, 4(1), 9-10.
Familylinks. (2014). Penn Free Bridge Housing. Retrieved November 10, from HYPERLINK "http://familylinks.org/index.php/housing/penn-free" http://familylinks.org/index.php/housing/penn-free
Feng, Y., He, X., Yang, Y., Chao, D., Lazarus, L. H., & Xia, Y. (2012). Current research on opioid receptor function. Curr Drug Targets, 13(2), 230-246.
Furst, S., Riba, P., & Al-Khrasani, M. (2013). New approach to the neurobiological mechanisms of addiction. Neuropsychopharmacol Hung, 15(4), 189-205.
Gardner, E. L. (2011). Addiction and brain reward and antireward pathways. Adv Psychosom Med, 30, 22-60. doi: 10.1159/000324065
Hall, G., Neighbors, C. J., Iheoma, J., Dauber, S., Adams, M., Culleton, R., . . . Morgenstern, J. (2014). Mobile opioid agonist treatment and public funding expands treatment for disenfranchised opioid-dependent individuals. J Subst Abuse Treat, 46(4), 511-515. doi: 10.1016/j.jsat.2013.11.002
Health Resources and Services Administration. (1999). Principles of Practice: A Clinical Resource Guide for Health Care for the Homeless Programs.
Health Resources and Services Administration. (2014). 2014 National Health Care for the Homeless Program Grantee Data. Retrieved 12/1/2015 HYPERLINK "http://bphc.hrsa.gov/uds/datacenter.aspx?q=t4&year=2014&state=&fd=ho" http://bphc.hrsa.gov/uds/datacenter.aspx?q=t4&year=2014&state=&fd=ho
Henwood, B. F., Padgett, D. K., & Tiderington, E. (2014). Provider views of harm reduction versus abstinence policies within homeless services for dually diagnosed adults. The Journal of Behavioral Health Services & Research, 41(1), 12. doi: 10.1007/s11414-013-9318-2
Horn, A., Whitehill, E., & Yonas, M. (2015). Homeless in Allegheny County - The client experience: Allegheny County Department of Human Services, Office of Data Analysis Research and Evaluation.
Indivior, I. (2015). Suboxone: Highlights of prescribing information. Richmond, VA.
Kertesz, S. G., Crouch, K., Milby, J. B., Cusimano, R. E., & Schumacher, J. E. (2009). Housing first for homeless persons with active addiction: Are we overreaching? The Milbank Quarterly, 87(2), 495-534. doi: 10.1111/j.1468-0009.2009.00565.x
Mann, C., Frieden, T., Hyde, P., Volkow, N., & Koob, G. (2014). Medication assisted treament for substance use disorders. Centers for Medicare & Medicaid Services Retrieved from https:// HYPERLINK "http://www.medicaid.gov/federal-policy-guidance/downloads/cib-07-11-2014.pdf" www.medicaid.gov/federal-policy-guidance/downloads/cib-07-11-2014.pdf.
McCoy, C. B., Metsch, L. R., Chitwood, D. D., & Miles, C. (2001). Drug use and barriers to use of health care services. Subst Use Misuse, 36(6&7), 789-8006.
McNeil, R., Kerr, T., Pauly, B., Wood, E., & Small, W. (2015). Advancing patient-centered care for structurally vulnerable drug-using populations: a qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals. Addiction. doi: 10.1111/add.13214
Meges, D., Zevin, B., Cookson, E., Bascelli, L., Denning, P., Little, J., . . . Williamson, J. (2014). Adapting your practice: Recommendations for the care of homeless patients with opioid use disorders (pp. 102). Nashville: Health Care for the Homeless Clinicians' Network.
National Coalition for the Homeless. (2009). Substance abuse and homelessness (July ed.). Washington, DC: National Coalition for the Homeless.
National Health Care for the Homeless Council. (2011, April). Frequently asked questions about health care for the homeless. Retrieved July 20, 2015, from HYPERLINK "http://bphc.hrsa.gov/technicalassistance/taresources/hchfaq2011.pdf" http://bphc.hrsa.gov/technicalassistance/taresources/hchfaq2011.pdf
Pennsylvania Department of Drug and Alcohol Programs. (2014). Pennsylvania Drug and Alcohol Annual Plan And Report 2014-2015.
Pennsylvania Department of Human Services. (2015, 7/20/2015). Preferred Drug List. Retrieved 11/30/2015, 2015, from HYPERLINK "http://www.providersynergies.com/services/documents/PAM_PDL.pdf" http://www.providersynergies.com/services/documents/PAM_PDL.pdf
Pennsylvania Medical Society. (2014, October 27). Prescription drug database soon a reality for PA physicians. Retrieved November 16, 2014, from HYPERLINK "http://www.pamedsoc.org/MainMenuCategories/Laws-Politics/News-from-Harrisburg/Legislation-News/CSDB.html" http://www.pamedsoc.org/MainMenuCategories/Laws-Politics/News-from-Harrisburg/Legislation-News/CSDB.html
Pittsburgh Mercy Health System. (2015). Operation Safety Net. Retrieved November 10, from https:// HYPERLINK "http://www.pmhs.org/operation-safety-net/" www.pmhs.org/operation-safety-net/
Prevention Point Pittsburgh. (2015). Retrieved November 10, 2015, from HYPERLINK "http://www.pppgh.org" www.pppgh.org
Roxane Laboratories, I. (2015). Methadone solution: Highlights of prescribing information. Columbus, OH.
Substance Abuse and Mental Health Services Administration. (2014). Substance use and mental health estimates from the 2013 national survey on drug use and health: overview of findings.
Substance Abuse and Mental Health Services Administration. (2015). Federal Guidelines for Opioid Treatment Programs. (HHS Publication No. (SMA) PEP15-FEDGUIDEOTP). Rockville, MD: Substance Abuse and Mental Health Services Administration.
Tringale, R., Subica, A. M., Danielian, A., & Kaplan, C. (2015). The stepped treatment engagement protocol for homeless, needle exchange heroin-dependent patients. J Addict Med, 9(2), 163-164. doi: 10.1097/adm.0000000000000096
Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, Consumer Choice, and Harm Reduction for Homeless Individuals With a Dual Diagnosis. Am J Public Health, 94(4), 651-656.
Tsemberis, S., Moran, L., Shinn, M., Asmussen, S. M., & Shern, D. L. (2003). Consumer preference programs for individuals who are homeless and have psychiatric disabilities: A drop-in center and a supported housing program. American Journal of Community Psychology, 32(3), 305-317.
Whelan, P. J., & Remski, K. (2012). Buprenorphine vs methadone treatment: A review of evidence in both developed and developing worlds. Journal of Neurosciences in Rural Practice, 3(1), 45-50. doi: 10.4103/0976-3147.91934
PAGE vi
PAGE 28
COMMUNITY-ORIENTED APPROACHES TO OPIOID ABUSE AMONG THE HOMELESS IN ALLEGHENY COUNTY: A LITERATURE REVIEW
by
Katie Lynn Naper
BA, Lawrence University, 2004
PharmD, University of Pittsburgh, 2012
Submitted to the Graduate Faculty of
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
2015
UNIVERSITY OF PITTSBURGH
GRADUATE SCHOOL OF PUBLIC HEALTH
This essay is submitted
by
Katie L. Naper
on
December 11, 2015
and approved by
Essay Advisor:
David Finegold, MD _________________________________
Director
Multidisciplinary MPH Program
Professor
Human Genetics
Graduate School of Public Health
University of Pittsburgh
Essay Readers:
Martha Ann Terry, PhD ________________________________
Assistant Professor
Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Christina Mair, PhD ________________________________
Assistant Professor
Behavioral and Community Health Sciences
Graduate School of Public Health
University of Pittsburgh
Copyright by Katie Naper
2015
David Finegold, MD
COMMUNITY-ORIENTED APPROACHES TO OPIOID ABUSE AMONG THE HOMELESS IN ALLEGHENY COUNTY: A LITERATURE REVIEW
Katie L. Naper, MPH
University of Pittsburgh, 2015
Table 1. Continued
R \ c
q
x
q
2 3 4 5 : G H ºzsogcg hvt6 j hvt6 Uh hee h hj, hj, hj, h$k h:Ii hf|. hQ) h;"` h1$ hyc hyc hyc j h_ UmH nH u h;v h;v h/x( 5h;v h;v 5h- j h- UmH nH u hA j h@m UmH nH u hY;N j hA UmH nH u&