Exploring opioid use disorder, its impact, and treatment among individuals experiencing homelessness as part of a family

doi:10.1016/j.drugalcdep.2018.04.012

Drug and Alcohol Dependence

Volume 188, 1 July 2018, Pages 161-168

https://doi.org/10.1016/j.drugalcdep.2018.04.012 Get rights and content

Highlights

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Family homelessness complicates how patients experience Opioid Use Disorder (OUD).
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We used interviews to assess how such patients experience OUD and treatment.
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Losing child custody and fear of passing OUD on to children were unique concerns.
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Childcare, transportation, and frequent moves were barriers to OUD treatment.
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Comprehensive, mobile, family-centered treatment may succeed in this population.

Abstract

Background

Opioid Use Disorder (OUD) causes significant morbidity and mortality among people experiencing homelessness. We aimed to explore the unique way in which OUD impacts individuals experiencing homelessness as part of a family.

Methods

We conducted semi-structured interviews with adults experiencing OUD staying in Boston-area family shelters along with dependent children. We used Borkan’s Immersion-Crystallization method to uncover themes from interview transcripts.

Results

We conducted 14 interviews. Eleven participants identified as female and three as male. Mean age was 35 (range 24–51) and median number of children was 2.5 (range 1-5). Emergent themes fell in three categories:

1) Initiation of OUD: Many patients were introduced to opioids through physician prescriptions, with recreational use coming first for some. Parents and partners also contributed to opioid use.

2) Impact of OUD: Overdose, homelessness, and unemployment were common impacts of OUD. Many patients described co-morbid chronic pain and mental illness. Psychosocial trauma, prominently due to loss of child custody, was common.

3) Treatment for OUD: Childcare, transportation to treatment at distant sites, and requirements that interfered with life responsibilities were barriers to treatment that shelter-based opioid treatment (SBOT) allowed patients to overcome. Family unity was universally seen as motivation for treatment.

Conclusions

According to a sample of adults experiencing OUD in the context of family homelessness, an ideal OUD treatment program would overcome logistical barriers, provide comprehensive treatment for comorbidities, support employment and housing needs, and focus care on the family. Future work should explore the generalizability and financial feasibility of this model.

Introduction

The opioid epidemic is a significant source of morbidity and mortality in the United States (Center for Behavioral Health Statistics and Quality, 2015). The epidemic has hit people experiencing homelessness particularly hard—in fact, in Massachusetts, overdose - primarily from opioids - is the leading cause of death in that population (Baggett et al., 2013). Research has shown that Office-Based Opioid Treatment (OBOT), which consists of comprehensive outpatient services including medication for OUD treatment, often integrated with voluntary behavioral therapies within a primary care setting—has similar outcomes in promoting sobriety and preventing overdose, both for adults experiencing homelessness and housed adults (Alford et al., 2007; LaBelle et al., 2016). However, many barriers on the patient-level (e.g., competing priorities such as food and housing security, or providing childcare), provider-level (e.g., stigma, workload) and system-level (e.g., family shelter placements far from treatment locations, stigma in shelter settings around possessing medication for OUD treatment) limit access to OBOT for those experiencing homelessness.

In the US, over one third of those experiencing homelessness are part of families and have unique and challenging experiences of healthcare compared to homeless adults without dependents (US Department of Housing, 2017; Wood and Valdez, 1991). Young women and their children—who make up the majority of family units experiencing homelessness—face unique health consequences of opioid use. For example, rates of both hepatitis C among women of child-bearing age and neonatal abstinence syndrome among infants are on the rise and pose significant health concerns (Tolia et al., 2015; Williams et al., 2011). In clinical practice, barriers specific to treatment of opioid use disorder (OUD) for these patients include the need for childcare during visits, concerns about accidental ingestion of prescribed opioid agonist medications by children, and the distance between family shelters and treatment sites.

The Boston Health Care for the Homeless Program (BHCHP) has served individuals and families experiencing homelessness since 1986. BHCHP’s Family Team consists of medical providers, behavioral health clinicians, nurses, and case managers who provide services at eleven different shelter- and motel/hotel-based clinics throughout greater Boston. In 2015, BHCHP’s Family Team implemented a family motel Shelter-Based Opioid Therapy (SBOT) program to help address this population’s unique concerns. As part of the SBOT model, waivered physicians prescribe buprenorphine onsite, transportation and childcare barriers are minimized, group or individual therapy is offered onsite and highly encouraged, and a care team is able to help families deal with competing priorities such as improving income and housing status (Chatterjee et al., 2017).

The social ecological model is a framework widely used in public health research and practice to explore and address multiple influences that shape health behaviors (Brofenbrenner, 1977). This model contextualizes the individual within an ecosystem that acknowledges health behavior as shaped by dynamic interactions between the individual and interpersonal, community, and societal factors. Among those experiencing substance use disorder in the context of homelessness, this model should be useful in designing treatment models. Yet, treatment of OUD typically still focuses on the individual-level clinical interaction—for example, in an otherwise comprehensive review article on treating patients with OUD, no mention is made of children or families, either in terms of impact of the disease or in planning treatment (Schuckit, 2016). Currently, there is a dearth of literature describing the experience of adults who suffer simultaneously from OUD and homelessness with their dependent children; there is also a lack of knowledge regarding what treatments these individuals prefer. Using this social ecological model as a framework, the aims of this study were to fill in gaps in the existing literature to describe the unique impact of the opioid epidemic on these particularly vulnerable families, to identify barriers to care, and to inform ways in which to improve care for this population.

Section snippets

Population and setting

We included individuals who were part of a family unit, living in Massachusetts, experiencing homelessness and OUD, and receiving care from Boston Health Care for the Homeless Program Family Team from between January 2015 and August 2017. In 2015, the BHCHP Family Team provided care to 1329 individual patients: 848 adults and 481 children. Four hundred and sixty-nine (35.3%) self-identified as Hispanic. Roughly 6% of the adult Family Team patients carried an International Classification of

Results

We completed 14 interviews, eleven in-person and three by phone. One individual stated that he wanted to participate but was not able to find a time to complete the interview; no additional individuals were approached and declined to participate. Eleven participants identified as female and three as male. Six participants were enrolled in SBOT, although one was receiving behavioral therapy without medication, six patients were enrolled in OBOT at other health centers or hospital practices, and

Discussion

In this qualitative study, a diverse group of individuals experiencing OUD and homelessness as part of a family unit provided insight into their experiences of opioid use and treatment. Prominent themes emerged, which included the role of physician prescribing in contributing to the development of substance use disorder following surgery or injury, and the reality that family members can sometimes prompt substance use or be a source of strength during difficult times precipitated by addiction.

Conclusion

In conclusion, results from this study suggest that efforts to treat OUD among those experiencing homelessness as part of a family should embrace an innovative vision that incorporates insights from the social ecological model. Effective treatment programs will need to be flexible and mobile, able to adapt to changing family life circumstances, and able to address physical and behavioral health needs of such individuals. Given that the number of deaths from opioid overdose continues to

Role of the funding source

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Contributors

Dr. Tishberg and Dr. Chatterjee developed the idea for the study and created the study design. Ms. Yu and Dr. Tishberg recruited patients and conducted and transcribed interviews. All three authors analyzed data and contributed to the manuscript. All three authors approved of the final version of the manuscript.

Conflict of interest

The authors have no conflicts of interest to disclose.

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Citation Excerpt :
Within each group, the study aimed to recruit at least five individuals who identified with non-white race/ethnicity and at least five individuals who identified as female. This purposeful sampling was important to reflect the diversity of PEH in Boston and other major cities (U.S. Department of Housing and Urban Development, 2020) and to account for findings that individuals who identify with Black race, Latinx ethnicity, and female gender have distinct experiences with OUD and treatment (Chatterjee et al., 2018; James & Jordan, 2018). A total of 29 individuals participated in this study.
People experiencing homelessness (PEH) make up a disproportionate share of opioid overdose fatalities. We set out to identify the facilitators and barriers that shape whether PEH initiate medications for opioid use disorder (MOUDs), both generally and after an overdose.
We conducted semi-structured interviews with 29 PEH in Boston who had self-reported history of opioid overdose. Seventeen participants had taken prescribed MOUD, and 12 had not. Using NVivo software we then coded transcripts applying the Borkan Immersion Crystallization method to identify individual, social, and structural factors influencing MOUD initiation.
Individual factors: Within the “timing” theme, non-fatal overdoses often led participants to feel sick with naloxone-induced withdrawal, decreasing treatment-seeking. By contrast, chronic opioid use consequences, like daily stress with finding drugs and shelter, increased interest in MOUD. Within the “medication benefits” and “medication concerns” themes, interest in MOUD initiation hinged on whether participants believed in or doubted MOUDs' effectiveness for reducing drug use. In a related theme, participants perceived that individuals must be “ready” in order for MOUDs to be effective.
Social factors: Within the “peer influence” theme, peers who use opioids were prominent sources of encouragement or deterrence for starting MOUD. “Family influence” emerged as a theme for participants with MOUD history.
Structural factors: Within the “health systems” theme, participants described that experiencing stigma from care providers toward people who use drugs was a barrier to MOUD. Within the “treatment systems” theme, regulations made methadone particularly difficult to access, even though nearly all participants had Medicaid coverage to pay for treatment. Within the “criminal justice systems” theme, participants reported frequent criminal justice involvement, with jails facilitating or preventing MOUD access.
Future interventions should (a) increase MOUD interest by messaging—ideally via peers—that MOUDs are effective for PEH and (b) increase MOUD access by making MOUDs available across health, treatment, and carceral systems. Mobile outreach and MOUD treatment would help reach PEH when they are facing daily opioid use disorder stressors and are more open to MOUD initiation. Future research should explore how racial, ethnic, and linguistic identities affect MOUD engagement among PEH.
The impact of social network dynamics on engagement in drug use reduction programs among men and women who use drugs
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Cross-sectional studies have shown strong relationships between social network characteristics and substance use disorder (SUD) treatment engagement. The current study examined associations between longitudinal changes in egocentric social networks of male and female people who use drugs (PWUD) and engagement in drug use reduction programs, broadly defined as either formal SUD treatment or self-help groups.
Using data from an HIV prevention and care study in Baltimore, MD, this study categorized PWUD into those who engaged and did not engage in any drug use reduction programs over two follow-ups during a one-year observation window. The study used multivariate logistic generalized estimating equations (GEE) to examine associations between network composition and stability measures and drug use reduction program engagement, stratified by gender.
Of the 176 subjects participating in drug use reduction programs at baseline, 56.3% remained engaged at one year. Among both male and female respondents, higher turnover into non-kin networks was associated with increased odds of engagement in drug use reduction programs (AOR 1.4; 95% CI: 1.1–1.9, AOR 1.3; 95% CI: 1.0–1.8, respectively). For males, retention of intimate partner networks was associated with increased odds of program engagement (AOR 2.9; 95% CI: 1.1–7.6); for females, higher turnover into kin networks was associated with decreased odds of engagement (AOR 0.8; 95% CI: 0.5–1.0).
Evaluation of associations between social network characteristics and drug use reduction program engagement appears to benefit from longitudinal analyses that are stratified by gender. Efforts to improve retention in formal SUD treatment or self-help groups might consider intervening through social networks, perhaps by increasing overall levels of social support.
Using administrative data to predict cessation risk and identify novel predictors among new entrants to opioid agonist treatment
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Longer retention in opioid agonist treatment (OAT) is associated with improved treatment outcomes but 12-month retention rates are often low. Innovative approaches are needed to strengthen retention in OAT. We develop and compare traditional and deep learning-extensions of Cox regression to examine the potential for predicting time in OAT at individuals’ first episode entry.
Retrospective cohort study in New South Wales, Australia including 16,576 people entering OAT for the first time between January 2006 and December 2017. We develop 12-month OAT cessation prediction models using traditional and deep learning-extensions of the Cox regression algorithm with predictors evaluated from linked administrative datasets. Proportion of explained variation, calibration, and discrimination are compared using 5 × 2 cross-validation.
Twelve-month cessation rate was 58.4%. The largest hazard ratios for earlier cessation from the deep learning model were observed for treatment factors, including private dosing points (HR=1.54, 95% CI=1.49–1.60) and buprenorphine medication (HR=1.43, 95% CI=1.39–1.46). Diagnostic codes for homelessness (HR=1.09, 95% CI=1.04–1.13), outpatient treatment for drug use disorders (HR=1.10, 95% CI=1.06–1.15), and occupant of vehicle accident (HR=1.04, 95% CI=1.01–1.07) from past-year health service presentations were identified as significant predictors of retention. We observed no improvement in performance of the deep learning model over traditional Cox regression.
Deep learning may be more useful in identifying novel risk factors of OAT retention from administrative data than evaluating individual-level risk. An increased focus on addressing structural issues at the population level and considering alternate models of care may be more effective at improving retention than delivering fully personalised OAT.
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Despite evidence that individuals with opioid use disorder (OUD) have a lower risk of mortality when using evidence-based medications for OUD (MOUD), only 20 % of people with OUD receive MOUD. Black patients are significantly less likely than White patients to initiate MOUD. We measured the association between various facilitators and barriers to initiation, including criminal justice, human services, and health care factors, and variation in initiation of MOUD by race.
We used data from a comprehensive, linked data set of health care, human services, and criminal justice programs from Allegheny County in Western Pennsylvania to measure disparities in MOUD initiation by race in the first 180 days after an OUD diagnosis, as well as mediation by potential facilitators and barriers to treatment, among Medicaid enrollees. This is a cross-sectional analysis.
Among 6374 Medicaid enrollees who met study criteria, Black enrollees were 18.2 percentage points less likely than White enrollees to start MOUD after controlling for gender, age, and Medicaid eligibility (95 % CI: -21.5 % - -14.8 %). Each day in the emergency department or county jail was associated with a decrease in the likelihood of initiation, as was the presence of a non-OUD substance use disorder diagnosis or participation in intensive non-MOUD treatment. Mediators accounted for approximately one-fifth of the variation in initiation related to race.
Acute care facilities and settings in which people with OUD are incarcerated may have an opportunity to increase the use of MOUD overall and close the racial gap in initiation.
Differential impacts of COVID-19 across racial-ethnic identities in persons with opioid use disorder
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Citation Excerpt :
Comorbid chronic lung disease may put individuals using opioids at elevated risk for severe complications from COVID-19, including hospitalization and death (National Institute on Drug Abuse, 2017). Compared to the general U.S. population, people with OUD have decreased access to health care, increased housing insecurity (Chatterjee et al., 2018), and higher rates of incarceration (U.S. Department of Justice, 2017), which cumulatively increase vulnerability for COVID-19 and pose challenges for accessing testing and care (Kar et al., 2020). Moreover, individuals' social and economic circumstances are likely to impact stigma and access to health care, limiting infectious disease testing (Hoyt et al., 2012) and substance use treatment access and utilization (Stringer & Baker, 2015).
The COVID-19 pandemic has exacerbated health disparities, particularly among at-risk people with opioid use disorder (OUD). We sought to characterize the direct and indirect impacts of COVID-19 on this group to understand how the pandemic has affected this group, this group's public health response to COVID-19, and whether there were differences by race/ethnicity.
This study recruited its sample from a drug treatment setting in the northeast region of the United States. We surveyed 110 individuals on methadone as treatment for OUD and assessed COVID-19-related impacts on their health behaviors and other indices of social, physical, and mental well-being, including sexual health behaviors, substance use, mental health status, health care access, income, and employment.
Our findings highlight overall increases in depression, anxiety, loneliness, and frustration among the sample of people with OUD; the study also observed decreases in financial stability. Significant differences between groups indicated a greater financial burden among racial-ethnic minorities; this subgroup also reported greater direct adverse effects of COVID-19, including being more concerned about contracting COVID-19, not being able to get a COVID-19 test, and knowing someone who had died from COVID-19. A greater proportion of Whites indicated increases in alcohol consumption and non–prescription drug use than did racial-ethnic minorities.
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Erratum: Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study (Drug and Alcohol Dependence (2021) 226, (S0376871621003847), (10.1016/j.drugalcdep.2021.108889))
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The majority (54 %) of Medicaid recipients did not enroll in opioid agonist therapy within 6 months. In adjusted models, having one or more prior overdose (adjusted risk ratio [ARR] = 0.43, 95 % CI: 0.37, 0.50), alcohol use disorder (ARR = 0.55, 95 % CI: 0.52, 0.59), or back problems (ARR = 0.56, 95 % CI: 0.54, 0.59) were strong predictors of non-enrollment. Conversely, emergency department (ARR = 1.20, 95 % CI: 1.18, 1.23) and primary care provider (ARR = 1.01, 95 % CI: 1.00, 1.02) visit frequency above the 75th percentile were associated with timely enrollment in opioid agonist therapy.
Our findings underscore the need to enhance pathways to treatment for OUD through varied nodes of engagement with healthcare systems. Interventions to improve screening for OUD and referrals to opioid agonist therapies should include high-impact settings, such as treatment programs for alcohol and substance use disorders, pain clinics, and outpatient behavioral care settings.

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Full length articleExploring opioid use disorder, its impact, and treatment among individuals experiencing homelessness as part of a family

Highlights

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Population and setting

Results

Discussion

Conclusion

Role of the funding source

Contributors

Conflict of interest

J. Subst. Abuse Treat.

J. Subst. Abuse Treat.

Addict. Behav.

J. Subst. Abuse Treat.

Treating homeless opioid dependent patients with buprenorphine in an office-based setting

J. Gen. Intern. Med.

Mortality among homeless adults in Boston: shifts in causes of death over a 15-year period

JAMA Intern. Med.

Immersion/Crystallization

Family-centered program deters substance use, conduct problems, and depressive symptoms in black adolescents

Pediatrics

Toward an experimental ecology of human development

Am. Psychol.

Behavioral Health Trends in the United States: Results from the 2014 National Survey on Drug Use and Health. (HHS Pulication No. SMA 15-4927, NSDUH Ser. H-50. 64

Shelter-based opioid treatment: increasing access to addiction treatment in a family shelter

Am. J. Public Health

“He was the story of my drug use life”: a longitudinal qualitative study of the impact of partner incarceration on substance misuse patterns among African American women

Subst. Use Misuse

Full length article
Exploring opioid use disorder, its impact, and treatment among individuals experiencing homelessness as part of a family