Estimates of the number of homeless people in the United States today vary considerably — from a low of 250,000 to as many as three million.1-3 However, there is little doubt that the numbers are growing and that homelessness is a critical problem that is spreading to communities outside major urban areas.4 The homeless population is disproportionately affiliated with serious health problems, including the heavy use of alcohol and other drugs which heighten the morbidity rate among the population. To date the response of government at all levels has been fragmented and ineffective which, in part, reflects a lack of understanding of how alcohol and other drug problems interact with the poverty cycle.
I. Statement of the Problem
A. The Homeless Population with Alcohol and Other Drug Problems
The results of recent research on the prevalence of alcohol and other drug problems among homeless persons are particularly clear on one point: that alcohol and other drug problems constitute the number one public health problem among this population. Studies conducted during the 1980s in Baltimore,5 Boston, New York City,6 Los Angeles,7 Portland (Oregon),8 Milwaukee, Columbus (Ohio),9 and Phoenix, and on a nationwide level10 show that, at a minimum, 30 percent of homeless people have alcohol problems. An additional 10 percent or more have histories of other drug problems.11
Today's homeless population is more diverse than in the past. It includes women, children, families, adolescents, people of color, the mentally ill, and users of other drugs, as well as the male skid row alcoholic. Their lives tend to be marked by multiple risk factors, including poverty, malnutrition, unemployment, physical disabilities, and mental illness, in addition to the complex problems arising from homelessness itself and use of alcohol and other drugs.12
The multiple causes of homelessness tend to be interrelated. They can be identified at both individual and societal levels. Significant decreases in the availability of low-cost housing, failure of entitlement and welfare programs to keep pace with the cost of living, and the decreased demand for unskilled labor are all societal factors which have affected individual lives and have contributed to the increased prevalence of homelessness. Since 1980, there has been a decline of 2.5 million low-income housing units in this country. During the same period of time, federal support for subsidized housing was reduced by 60 percent. Approximately half a million units are still being lost each year through conversion, abandonment, fire, and demolition.4
On an individual level, persons who have a problem with alcohol and/or other drugs, and who are in marginal economic circumstances, are at especially high risk for homelessness. Risk increases when use of alcohol and other drugs leads to the loss of a job, an eviction notice, or an incident of domestic violence. Moreover, displacement to a hotel, shelter, or the streets can exacerbate the problem; homeless individuals may turn to drink and/or other drugs to numb their senses from the difficulties encountered in these settings.12 Whether alcohol and/or other drug use is an antecedent to, or the consequences of homelessness, it clearly exacerbates the problems of homelessness.
B. Public Health Issues
The use of alcohol and other drugs by homeless persons often leads to serious acute and chronic physical disorders. Homeless individuals experience inordinately high rates of respiratory ailments, trauma, cardiovascular disease, and diseases directly linked to alcohol and drug use, including liver diseases and seizure disorders.10,13,14 Homeless individuals with alcohol problems tend to be undernourished and debilitated and, as a result, have compromized immune systems.15 Recent clinical reports also indicate that, in some cities, high percentages of homeless people are infected with the human immunodeficiency virus (HIV) or have AIDS (acquired immunodeficiency syndrome).16 Not surprisingly, morbidity and mortality rates among homeless people with alcohol and other drug problems are high.14
Homeless intraveneous drug users, living on the streets or in shelters, are found among both hospitalized persons with AIDS and those at increased risk for HIV infection.
Another health problem facing homeless people having alcohol and other drug problems is mental illness. Research suggests that a minimum of 15 percent of homeless people with alcohol and other drug problems also suffer from psychiatric disorders.17-19 Findings from a recent survey conducted in Los Angeles indicate that 14.5 percent of inner-city homeless people have serious alcohol problems and also a lifetime diagnosis of schizophrenia; 33 percent have alcohol problems and a lifetime diagnosis of major affective disorders.12
Collectively, the research demonstrates that the homeless population with alcohol and other drug problems face physical and psychiatric disorders, all of which complicate the problems of securing food, housing, employment, income assistance, and medical care.
C. Service Gaps
In most cities, health and human service systems are not capable of dealing with the range of difficulties homeless individuals with alcohol and other drug problems present. Services that are available for homeless persons with alcohol and other drug problems are often fragmented. This lack of coordination among service providers is most evident in efforts directed toward the homeless person with concomitant mental illness, and alcohol and/or drug problems. Many community mental health centers do not have the capacity to treat alcohol and/or drug problems, while many drug/alcohol recovery programs are not equipped to serve mentally ill clients. In addition, coordination is often lacking between primary recovery agencies and support service systems providing basic services such as vocational training and social services. Finally, the demand by the homeless population for medical attention exceeds the supply and contributes to increased medical costs.
The criminal justice system, likewise, is ill-equipped to handle homeless individuals having alcohol and other drug problems. The police, often the first to encounter homeless people on the streets, spend an inordinate amount of their duty time (at an enormous cost to the public) in dealing with misdemeanors and complaints that typify homeless populations.20 Available evidence from jail and shelter studies indicates that as many as 50 to 75 percent of homeless individuals with alcohol and other drug problems have had recent arrests and at least one jail confinement.21 Efforts by police and courts to divert misdemeanor offenders to community agencies that treat alcohol, drug, or other health problems are frequently thwarted by their limited space and inability to handle the multitude of interrelated problems of homeless people.
D. Priorities for Responding to the Needs
Research on homelessness associated with alcohol and other drug problems suggests that four priorities should be established in responding to the needs 1) innovative treatment strategies and recovery approaches; 2) affordable housing opportunities; 3) policy initiatives; and 4) research and evaluation.
1. Treatment Strategies/Recovery Approaches —
Treatment professionals should be encouraged to develop creative recovery programs that are sensitive to the diverse problems and personal backgrounds among homeless people with alcohol and other drug problems. The Institute of Medicine report, for example, recommends outreach services, supportive living environments, specialized case management, and appropriate rehabilitation services.4
The Community Demonstration Grant Projects for Alcohol and Drug Abuse Treatment of Homeless Individuals of the National Institute on Alcoholism and Alcohol Abuse (NIAAA) include nine demonstration programs that incorporate these services.22 The demonstration models being tested and evaluated combine treatment, case management, housing, and environmental strategies designed to serve homeless men, women, and families. These models are only a start. The unique characteristics of each community, and the heterogeneity of the homeless population, require that multiple strategies be developed, implemented, and systematically evaluated. Through such efforts, successful interventions will be identified. It is also clear that treatment and recovery approaches need to include a variety of support and housing services to be effective for this population. Ongoing support for the development of service innovations is critical.
There is evidence to support the recommendation that treatment and recovery approaches should not be limited to professional interventions. Self-help models have been highly successful in helping individuals recover from alcohol and other drug problems and in preventing relapses. Long-term sobriety without peer support is extremely unlikely. In addition, sobriety cannot be maintained without adequate housing and job training.
Treatment providers now report significant numbers of individuals with more than one disability.22 Those who have alcohol and other drug problems and who are also mentally ill are especially difficult to serve, since treatment and recovery systems are typically designed to address singular problems, not multiple diagnoses. We must therefore make meaningful progress in developing more suitable treatment strategies and recovery approaches, such as cross-funding of service programs and referral networks, so we can offer treatment and recovery services regardless of the complexity of the disability. This requires continued cooperation and collaboration of funding sources at the federal, state, and local levels and cooperation and collaboration among service providers themselves.
2. Housing Opportunities —
More than anything else, homeless people need stable residences. The Institute of Medicine in 1988 concluded that "decent housing was essential to the prevention of disease and promotion of health" among homeless populations.4 However, housing alone is not sufficient for homeless people with alcohol and other drug problems. Recovery will be difficult to maintain unless the housing is alcohol and drug-free.
Not surprisingly, researchers report that most homeless clients do not have alcohol-free, physically secure places to live after completing an alcohol recovery program. Discharged to "self-care" or "general welfare" and advised to attend Alcoholics Anonymous meetings, these clients are prone to resume drinking.24
Alcohol and other drug-free housing is usually self-help oriented and most appropriate for individual who have completed a treatment recovery program and achieved a period of sobriety.25 The primary "house" rule is complete abstinence from alcohol and other drugs. Actual programs vary from a single room occupancy hotel to a network of rented houses. Many men and women have indicated that they can sustain their recovery by living with like-minded friends in a sober environment. Also, the availability of alcohol-free and drug-free housing is a positive influence on homeless individuals who may not have an alcohol or other drug problem. Clearly, public and private efforts to increase the availability of housing that is alcohol and drug free are critical to assisting more homeless individuals in their recovery.
3. Policy Initiatives —
Public policy often has negative, albeit unintended, impacts on the homeless population. Local, state, and federal policies and rules must be more sensitive to the problems that confront homeless individuals having alcohol and other drug problems. A significant portion of federal alcohol and drug block grant funds should be set aside for services to the indigent population, with a special emphasis on the homeless population. One of the more insidious public policies prohibits recovering men and women from public housing if they have been incarcerated or convicted of alcohol- or drug-related crimes. The policy not only prevents individuals who have documented sobriety from returning to public housing, it also hampers treatment/recovery efforts. Some individuals may be reluctant to acknowledge drug and/or alcohol problems, afraid such disclosures will result in loss of housing. Also, this policy might prevent recovering men and women from "modeling" their sobriety, serving as examples for other residents in recovery programs. Without sensitivity to the need for treatment and the benefits of recovery, public housing will remain drug- and alcohol-infested.
More general policy perspectives should examine the availability of alcohol and other drugs in the inner-city districts where homeless people congregate. These areas often contain alcoholic beverage outlets (liquor stores and bars) and places where other drugs are readily available. Increased regulation of beverage alcohol outlets and more rigorous enforcement of alcohol and drug ordinances by city and state enforcement agencies will lead to a reduction in problematic alcohol consumption and alcohol- and drug-related problem behaviors. Particular attention should be given to restricting the sale of fortified wines marketed primarily in inner-city or skid row districts since fortified wine is widely consumed by homeless people. The packaging and low cost of fortified wines make them especially attractive to the homeless population. Usually sold in half-pint hip flasks known as "short dogs," fortified wines offer high alcohol content at a very low price and may well contribute to problems associated with public intoxication. Local policymakers should be encouraged to address the sale of fortified wines through local regulations, planning, and zoning. A ban on the sale of fortified wine in Portland, Oregon, for example, reduced merchant complaints about public inebriates.26 In addition, state and federal policymakers should consider the public health implications of the marketing and sale of any fortified wines.
Overall, poverty is the underlying issue and homelessness is an outcome of poverty and other factors. The many hazards of being poor—ill health, inadequate or non-existent housing, availability of cheap alcohol — are conditions aggravated among homeless people. Hence, responses to homelessness must look beyond provision of temporary shelter and address the myriad problems of extreme poverty.
4. Research and Evaluation—
Systematic research and evaluation are necessary to monitor treatment interventions/recovery approaches, identify special subpopulations of the homeless, assess needs, and evaluate the impact of treatment/recovery and housing policies and initiatives. Professionals in public health, medicine, social and behavioral sciences, and social welfare must be encouraged to place a high priority on research regarding homeless populations having alcohol and other drug problems. Systematic research and evaluation can help identify concepts and approaches that are most effective with specific clientele and test the replicability of promising interventions.
II. Purpose and Objectives
The purpose of this position paper is to 1) heighten awareness among APHA members, the professional community, the general public, and policymakers as to the crisis of homelessness and its relation to alcohol and other drug problems; 2) bring the APHA into a leadership role in efforts to promote an organized platform of policy changes and social action; and 3) contribute professional support for research programs on this population and to recovery approaches linked to housing, employment, and income needs.
The APHA Section on Alcohol and Drugs has urged the Association to endorse the following priorities:
III. Action Desired and Methods to Be Used
The APHA Section on Alcohol and Drugs believes that, by adopting this position paper, APHA will assume a leadership role in educating professionals and policymakers about alcohol and other drug problems among homeless populations. Hopefully, this will lead to appropriate policy reforms and strategies required to address the needs.