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