Hazardous drinking and its association with homelessness among veterans in care
Introduction
Veterans are a population at increased risk for alcohol misuse and homelessness (Goldstein et al., 2008, HUD, 2008a, HUD, 2008b). In a recent study, the Department of Veterans Affairs (VA) identified 800,000 veterans with substance use and alcohol use disorders (McKellar and Dalton, 2006). In a national study conducted on the non-institutionalized general population in the U.S., almost 57% of veterans reported alcohol use in the last month, significantly higher than those who reported use among the non-veteran population. Moreover, 23% of veterans reported episodes of heavy episodic drinking (Wagner et al., 2007). The same proportion of veterans reported drinking almost daily in the past year, which was significantly higher than the prevalence of daily consumption in the general population (Tessler et al., 2005). Scholars have also documented a high prevalence of homelessness among veterans. The VA estimates that on any given day, approximately 75,000 veterans are in emergency shelters or transitional housing and comprise 15% of the shelter population of the U.S. (HUD, 2008a, HUD, 2008b).
Alcohol use has been referred to as a pandemic among homeless veterans (Goldstein et al., 2008) significantly increasing their homeless tenure (O’Connell et al., 2008) and preventing their exit from current homelessness (Gregoire, 1996). Common risk factors for both alcohol use and homelessness include age (Bray et al., 2002, Cannon et al., 1990, Ferrier-Auerbach et al., 2009, Rosenheck et al., 1994), race (HUD, 2008a, HUD, 2008b, Jacobson et al., 2008, Rosenheck et al., 1994), gender (Bradley et al., 2006, Gamache et al., 2003, Ross et al., 1998), poverty (HUD, 2008a, HUD, 2008b, Khan et al., 2002, Sosin and Bruni, 1997), illicit substance use (O’Connell et al., 2008, Rounsaville et al., 2003, Rosenheck and Fontana, 1994) and mental illnesses such as depression (Desai et al., 2003, Ghose et al., 2011, Jakupcak et al., 2010, Kuno et al., 2000, Prigerson et al., 2003), schizophrenia (Drake et al., 1989, Etter and Etter, 2004) and posttraumatic stress disorder (PTSD; O’Connell et al., 2008, Shipherd et al., 2005, Steindl et al., 2003).
However, research has not examined the direct link between alcohol use and transitioning into homelessness among veterans. Moreover, while research on alcohol use among veterans has tended to focus on more severe alcohol use disorders such as alcohol abuse and dependence, little is known about the outcomes of lower levels of misuse such as hazardous use. The World Health Organization defines hazardous use as a subthreshold (i.e., below the threshold of abuse or dependence) form of heavy drinking, which consists of a repeated pattern of drinking that confers the risk of harm (Conigliaro et al., 2003, Rinaldi et al., 1988, Sanchez-Craig et al., 1995, Saunders and Lee, 2000). This definition of hazardous drinking has been accepted by the ICD-10 and usually corresponds to 16 or more drinks a week for men and 12 or more for women. The move from an emphasis on alcohol dependence to lower thresholds of consumption mirrors a similar shift in mental health, where subthreshold levels of symptoms have been found to be more prevalent and cause significant functional impairments (Saunders and Lee, 2000).
Examining the link between transitioning into and out of hazardous drinking on homelessness might inform the use of early interventions with alcohol users in order to increase the likelihood that they remain housed. Moreover, scholars note that studies examining the link between addictive disorders and homelessness have generally not differentiated between disorders that preceded homelessness and those that followed it (Winkleby et al., 1992). Thus the longitudinal link between alcohol use and homelessness has been largely unexamined. This research seeks to address these issues by examining the effects over time, of hazardous drinking on homelessness in the Veterans Aging Cohort Study (VACS), a sample of 2898 older veterans attending the general medical clinic of 8 VAs across the country. We hypothesize that after controlling for other correlates: (a) hazardous drinking at baseline is positively associated with homelessness at follow-up, (b) transitioning to hazardous drinking from baseline to follow-up is positively associated with homelessness at follow-up, (c) reducing hazardous drinking to non-hazardous levels from baseline to follow-up is negatively associated with homelessness at follow-up, and (d) transitioning to hazardous drinking is positively associated with transitioning to homelessness from baseline to follow-up.
Section snippets
Sample
The VACS is a longitudinal study of HIV-infected and uninfected patients seen in VA infectious disease and general medical clinics. The study examines the role of alcohol and comorbid medical and psychiatric disease on clinical outcomes in HIV infection. Initiated in 2002, the eight-site study includes veterans being treated in VAs in Atlanta, Baltimore, New York, Houston, Los Angeles, Pittsburgh, and Washington, DC. Subjects were randomly selected from the VA Immunology Case Registry of all
Results
The rates of hazardous drinking were high: 35.9% (1018) were engaging in it at baseline, 23.2% (658) were drinking at that level at the one-year follow-up, 10.2% (289) increased their drinking to hazardous levels through the year, and 17.9% (506) decreased consumption from hazardous to non-hazardous levels during that same time (Table 1). Of the veterans in this sample, 5.6% (159) were homeless at baseline, 7.3% (206) were homeless at one-year follow-up and 4.6% (131) were housed at baseline,
Discussion
The results highlight a unique set of associations between alcohol consumption and homelessness, which have important clinical and policy implications for care. Hazardous drinking at baseline, after controlling for levels of drinking that indicated alcohol dependence, was associated with homelessness at follow-up. Moreover, transition to hazardous drinking over the course of the year was one of the factors most significantly associated with being homeless at follow-up. Economic vulnerability
Role of funding source
This work was financially supported by National Institutes of Health: NIAAA (U10-AA13566), NHLBI (R01-HL095136; R01-HL090342; RCI-HL100347), and NIA (R01-AG029154; K23 AG024896). The funding helped support the implementation of the study, i.e., the implementation of the study design, the data collection process and preparation of the data for analysis. The funders played no role in the analysis of the data, the preparation of the manuscript or decisions regarding where to submit it.
Contributors
T. Ghose conducted the statistical analyses, and took the lead author's role in preparing the final manuscript. A. Justice, D. Feillin, M. Goetz and M. Rodriguez-Barradas designed the study, supervised the data collection process, helped in the analyses, provided feedback on the manuscript, and helped in authoring the final manuscript. A. Gordon, S. Metraux, O. Blackstock and K. McInnes conducted the literature review, interpreted the results of the statistical analyses, provided feedback on
Conflict of interest
No conflict declared.
Acknowledgements
We acknowledge the Veterans who participate in the Veterans Aging Cohort Study and the study coordinators and staff at each of our sites and at the West Haven Coordinating Center. We acknowledge the substantial in-kind support we receive from the Veterans Affairs Healthcare System.
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