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Homelessness and Substance Abuse: Which Comes First?


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The present paper uses a social selection and social adaptation framework to investigate whether problematic substance use normally precedes or follows homelessness. Clarifying temporal order is important for policy and program design. The paper uses information from a large dataset (N�4,291) gathered at two services in Melbourne, supplemented by 65 indepth interviews. We found that 43% of the sample had substance abuse problems. Of these people, one-third had substance abuse problems before they became homeless and two-thirds developed these problems after they became homeless. We also found that young people were more at risk of developing substance abuse problems after becoming homeless than older people and that most people with substance abuse issues remain homeless for 12 months or longer. The paper concludes with three policy recommendations.
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Australian Social Work
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Homelessness and Substance Abuse: Which Comes First?
Guy Johnson a; Chris Chamberlain a
a RMIT University, Victoria, Australia
Online Publication Date: 01 December 2008
To cite this Article Johnson, Guy and Chamberlain, Chris(2008)'Homelessness and Substance Abuse: Which Comes First?',Australian
Social Work,61:4,342 — 356
To link to this Article: DOI: 10.1080/03124070802428191
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Homelessness and Substance Abuse:
Which Comes First?
Guy Johnson & Chris Chamberlain
RMIT University, Victoria, Australia
The present paper uses a social selection and social adaptation framework to investigate
whether problematic substance use normally precedes or follows homelessness. Clarifying
temporal order is important for policy and program design. The paper uses information
from a large dataset (N4,291) gathered at two services in Melbourne, supplemented
by 65 indepth interviews. We found that 43% of the sample had substance abuse
problems. Of these people, one-third had substance abuse problems before they became
homeless and two-thirds developed these problems after they became homeless. We also
found that young people were more at risk of developing substance abuse problems after
becoming homeless than older people and that most people with substance abuse issues
remain homeless for 12 months or longer. The paper concludes with three policy
Keywords: Homelessness; Substance Abuse; Housing And Support
There is a common perception that substance abuse and homelessness are linked, but
there is considerable contention about the direction of the relationship (Kemp, Neale,
& Robertson, 2006; Mallett, Rosenthal, & Keys, 2005; Neale, 2001; Snow & Anderson,
1993). Does substance abuse typically precede or follow homelessness? In the present
paper, we distinguish between recreational substance use and problematic substance
use, or substance abuse. First, we review the literature; then, we explain how we
operationalised the terms ‘‘problematic substance use’’ and ‘‘substance abuse’’ in our
Some studies indicate that substance abuse is a risk factor for homelessness,
whereas others suggest that homelessness ‘‘induces drug use’’ (Neale, 2001, p. 354).
This is commonly known as the debate about substance abuse as either a cause or
Correspondence to: Dr Guy Johnson, Australian Housing and Urban Research Institute, RMIT University, GPO
Box 2476V, Melbourne, Vic. 3000, Australia. E-mail:
Accepted 21 July 2008
ISSN 0312-407X (print)/ISSN 1447-0748 (online) #2008 Australian Association of Social Workers
DOI: 10.1080/03124070802428191
Australian Social Work
Vol. 61, No. 4, December 2008, pp. 342356
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consequence of homelessness (Culhane, 2005; Hartwell, 2003; Morrell-Bellai,
Goering, & Boydell, 2000; Neale, 2001; Neil & Fopp, 1993; Victorian Homelessness
Strategy, 2002). We also refer to this debate as the argument about temporal order, or
what comes first.
Johnson, Freels, Parsons, and Vangeest (1997) also referred to the argument about
cause and consequence, but they frame the debate using the ideas of social selection
and social adaptation. The social selection model views substance abuse as just one of
a number of causes or triggers of homelessness. Some studies suggest that substance
abuse is the major reason for homelessness (Baum & Burnes, 1993), whereas others
suggest that it is just one of many contributing factors (Neale, 1997; Snow &
Anderson, 1993; Timmer, Eitzen, & Talley, 1994).
The key proposition underpinning the social selection model is that homelessness
represents the end point in a process characterised by the gradual depletion of an
individual’s economic and social resources. As people’s substance use increases, so
their financial reserves are exhausted as they maintain an increasingly expensive
‘‘habit’. They either fall into rent arrears, which leads to eviction (Bessant et al.,
2002), or family relationships break down, leading to homelessness (Coumans &
Spreen, 2003). Fountain and Howes found that 63% of their sample of homeless
people in Britain cited drug or alcohol use as a reason for first becoming homeless.
They concluded that ‘‘Drug use is traditionally seen as one of the major routes into
homelessness, and this was borne out by our survey’’ (Fountain & Howes, 2002,
p. 10).
Media commentaries in Australia imply that problematic drug use is a major cause
of homelessness (Zufferey & Chung, 2006) and people in the wider community
apparently endorse this position. In a recent survey of 993 people in Melbourne, 91%
identified substance abuse as the primary cause of homelessness (Hanover Welfare
Services, 2006).
The social adaptation model focuses on substance abuse as a consequence of
homelessness. It draws upon the long established sociological argument that social
behaviour can be best understood by examining the social context in which it occurs.
Newly homeless people encounter an environment where substance use is an accepted
social practice. For some people, involvement with drugs stems from their initiation
or socialisation into the homeless subculture (Auerswald & Eyre, 2002; Ginzler,
Cochran, Domenech-Rodriguez, Cauce, & Whitbeck, 2003; Hartwell, 2003; Johnson,
Freels, Parsons, & Vangeest, 1997; Johnson, Gronda, & Coutts, 2008; Rice, Milburn,
Rotheram-Borus, Mallett, & Rosenthal, 2005). For other people, drug use emerges as
a means of coping with the uncertainty, instability, and chaotic conditions that
characterise their day-to-day lives (Neale, 2001; Rowe, 2002; Teesson, Hodder, &
Buhrich, 2003). Although individuals respond in ways that make sense to them, the
thrust of this argument is that the behaviour of the homeless is best understood as an
‘‘adaptation to environmental exigencies’’ (Snow & Anderson, 1993, p. 38).
This paper draws on a large sample of homeless people (N4,291) to investigate
whether substance abuse normally precedes or follows homelessness. This is a
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complicated issue because there is considerable variation between individual cases
and homelessness is rarely caused by one factor operating independently. We show
that both approaches help to understand the relationship between homelessness and
problematic substance use. Nonetheless, we argue that it is more common for
substance abuse to follow homelessness rather than to precede it. We also show that
young people are particularly vulnerable to developing problematic substance abuse
in the homeless population, and that people who have substance abuse problems
usually remain homeless for 12 months or longer. Finally, we make three policy
We collected information at two high-volume services in inner Melbourne. Both
agencies work with people who are at risk of homelessness, as well as those who are
actually homeless. On average, each agency works with 6,0007,000 households each
year. A case file is created for every household that presents to each service and we
obtained permission to read these case files from both agencies and our university ethics
At one agency, the protocol was that clients must give written consent for us to
examine their case file. At the other agency the protocol was that clients could opt out of
the research by signing a form. The case files could not be de-identified because they
were currently in use by staff at both services, but clients’ names were not recorded and
each record was allocated a number for identification purposes. Many files contained a
great deal of retrospective information about people’s housing histories and we could
follow people’s experiences of homelessness over many months or years.
First, we discuss the definition of homelessness used in the research and the
representativeness of our sample. Then we explain how we operationalised the terms
problematic substance use and substance abuse. Finally, we explain how we used
qualitative data to supplement the quantitative database.
The number of homeless people in our sample depends on the definition of
homelessness that is used. In Australia, there has been debate about the definition of
homelessness, with disagreement about many fundamental issues (Chamberlain &
Johnson, 2001; Crane & Brannock, 1996; Neil & Fopp, 1993). In the present paper, we
use an approach known as the ‘‘cultural definition of homelessness’, which the
Australian Bureau of Statistics uses to enumerate the homeless population (Chamber-
lain, 1999; Chamberlain & Mackenzie, 2003).
The core idea underpinning the cultural definition of homelessness is that there are
shared community standards about the minimum accommodation that people can
expect to achieve in contemporary society (Chamberlain & MacKenzie, 1992). The
minimum for a single person (or couple) is a small rental flat with a bedroom, living
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room, kitchen, and bathroom, as well as an element of security of tenure provided by a
lease. This has led to the identification of ‘‘primary’, ‘‘secondary’’, and ‘‘tertiary’’
Primary homelessness includes all people without conventional accommodation,
such as people living on the streets or using cars or railway carriages for temporary
shelter. Secondary homelessness includes people who move frequently from one form
of temporary shelter to another, including emergency accommodation. Tertiary
homelessness refers to people staying in boarding houses on a medium- to long-term
basis, defined as 13 weeks or longer. These people are homeless because their
accommodation does not have the characteristics identified in the minimum
community standard.
We examined a total of 5,526 cases over the period January 2005June 2006 and
coded each file on 30 variables, including whether the household was ‘‘homeless’’ or
‘‘at risk’. We identified 334 cases in which people had been coded at both agencies
and these duplicates cases were removed from the database, along with six cases that
contained insufficient information. This reduced the database to 5,186 households. In
the present paper, we are only interested in the homeless population and we had
information on 4,291 homeless households.
There is no sampling frame of homeless people in Australia and this makes it difficult
to assess the typicality of our sample. Nonetheless, we suspect that the sample is
representative of the inner city homeless for two reasons. First, we drew our data from
the two principal high-volume services in the inner city. Second, when we compared the
demographic characteristics of the sample (e.g. age, household type, gender) with the
characteristics of the population using the services, the two profiles were similar.
Substance Abuse
The number of people identified with substance abuse problems depends on the
definition of problematic substance use that is used. Defining substance abuse tends to
follow either clinical or operational approaches, both of which have limitations (for a
useful summary, see Snow, Anderson, & Koegel, 1994).
In the present paper, we distinguish between ‘‘recreational’’ substance use and
‘‘problematic’’ substance use or substance ‘‘abuse’. We operationalise problematic
substance use or substance abuse following the work of Mallett, Edwards, Keys, Myers,
and Rosenthal (2003). Problematic substance use is when drug use dominates a person’s
life at the expense of other activities and has negative mental and/or physical side effects.
We classified people as having a substance abuse problem if they met at least one of the
following criteria:
.the individual had approached the agency for a referral to a drug treatment service;
.the individual was currently in, or had been in, a detoxification or rehabilitation
centre; or
.the case notes identified substance abuse as an issue.
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Problematic substance abuse was often self-reported, but sometimes it was based
on an assessment made by staff.
Clarifying the chronological sequence of homelessness and substance abuse is
difficult and, in itself, insufficient to establish causal linkages (Johnson et al., 1997).
Nevertheless, at both agencies, staff endeavoured to make a broad-based assessment
of the issues that resulted in the person becoming homeless. Housing and support
workers know that problematic substance use is often an issue for presenting clients
and they are used to asking questions to ascertain whether this is relevant.
Problematic substance use is routinely recorded on the case file with brief details.
We used information from the initial assessment, often combined with information
from other parts of the case history, to assess whether substance abuse preceded or
followed homelessness.
Our findings provide an indicator of the extent of problematic substance use
among the inner city homeless, although it may be an underestimate because some
people may not have disclosed this information. Similarly, our findings provide an
indicator of whether substance abuse precedes or follows homelessness, but relevant
information may have been missing from some case histories.
Qualitative Data
There are limitations in determining how processes unfold when using quantitative
data. Therefore, we supplement our analysis with information from 65 indepth
interviews. The use of multiple techniques is known as ‘‘triangulation’’ and this is a
standard approach in the social sciences: ‘‘triangular techniques ...attempt to map
out, or explain more fully the richness and complexity of human behaviour by
studying it ...using a variety of methods, even combining qualitative and
quantitative methods’’ (Burns, 1994, p. 272).
The 65 respondents were recruited from the participating agencies. Agency staff
recruited people who were or had been homeless and were willing to participate in
the study. Approval was obtained from our university ethics committee. A cross-
section of homeless people using the agencies was interviewed and they matched the
main sample in terms of basic social characteristics, such as age, gender, and
household type. Half the respondents had substance abuse issues, and some
interviews elicited a great deal of information about substance abuse and the process
of becoming homeless. On average, the interviews lasted an hour.
The interviews were tape recorded and transcribed for qualitative analysis. We used
narrative analysis to organise information according to temporal sequence (Labov,
1997), paying particular attention to pathways into and out of homelessness,
engagement with the homeless subculture, and whether substance abuse preceded of
followed homelessness. We use the qualitative data to illustrate what happens when
substance abuse precedes homelessness and what happens when substance abuse
follows homelessness. People’s names and various personal details have been changed
to ensure confidentiality.
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Prevalence of Substance Abuse
The first task was to establish how many people in the sample had substance abuse
problems. Studies that focus on the number of people with substance abuse problems
are referred to as prevalence studies. A common finding is that homeless people have
higher rates of problematic substance use than people in the general community
(Teesson, Hodder, & Buhrich, 2003). In their recent study of 210 homeless people in
Sydney, Teesson et al. (2003, p. 467) found that ‘‘homeless people were six times more
likely to have a drug use disorder and 33 times more likely to have an opiate use
disorder than the Australian general population’’. One welfare service in Melbourne
reported that the prevalence rate of heroin use among its clients was ‘‘10 times greater
than in the general community’’ (Horn, 2001, p. 8).
Although the empirical link between substance abuse and homelessness is well
established, reported rates of problematic drug use among the homeless vary, with
estimates ranging from 25% to 70% (Hirst, 1989; Jordon, 1995; Victorian Home-
lessness Strategy, 2002). Estimates vary because of different sampling procedures, as
well as different definitions of problematic drug use and homelessness.
We found that 43% of our sample had substance abuse problems. The most
common drug was heroin, but a minority identified alcohol or prescription drugs.
Our findings are consistent with recent studies indicating that drugs have displaced
alcohol as the most abused substance among the homeless, particularly among the
young (Glasser & Zywiak, 2003; Johnson et al., 1997).
Substance Abuse as a Precursor to Homelessness
The first model we examine is the social selection approach. We start by identifying
how many people in our sample had substance abuse issues prior to becoming
homeless. Then, we identify three typical stages leading to homelessness for those
with problematic drug use.
We found that 15% of the sample had substance abuse problems prior to becoming
homeless for the first time. In the public domain, substance abuse is regularly seen as
the main cause of homelessness, yet for most people in our sample other factors
resulted in them becoming homeless. This finding is important for two reasons. First,
when attributions of cause are incorrect, it can lead to inappropriate policy and
program design. Second, by focusing on substance abuse as a causal factor,
individuals are commonly blamed for the situation, diverting attention away from
the structural factors that contribute to homelessness.
Many people in Australia use drugs for recreational purposes (Marks 1989;
McAllister & Makkai, 2001), but here we describe the substance abuse pathway into
homelessness. Studies of homeless pathways commonly point to a series of ruptures
with mainstream life (Hartwell, 2003; Johnson et al., 2008; Keys, Mallett, &
Rosenthal, 2006). We identify three stages in the substance abuse pathway. First,
there is a break with the mainstream labour market; second, there is the loss of
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support from family and friends; and, finally, there is the acquisition of new social
The first stage is characterised by people’s changing relationship with the labour
market. Substance abuse often starts to interfere with people’s ability to work,
commonly leading to job loss (Bessant et al., 2002; Zlotnick, Robertson, & Tam,
2002). For example, Cynthia
was a hairdresser working in a regional city. After
dabbling in drugs for a number of years, she was introduced to heroin by her
boyfriend. Over time her heroin use became more frequent and she started ‘‘working
extra hours’’ to support her habit. Slowly her ‘‘habit’’ burgeoned out of control and
her work ‘‘started to get messy’’. Cynthia left before she was sacked but, in a country
town, rumours spread quickly and she was unable to find alternative employment.
Andrew, a storeman, had a similar experience. As his heroin use escalated, he
started to miss work more frequently, citing a range of illnesses and problems at
home to explain his repeated absences. Eventually, he ended up ‘‘having to leave that
job’. He got another job, but ‘‘they suspected I was using’’ and he was sacked.
When people lose their jobs, it is the loss of income that has the biggest impact.
People start to look for alternative sources of income to support their habit, what
Rowe (2002) called the ‘‘business of raising money’. This ‘‘business’’ has a significant
influence on people’s day-to-day lives, because the cost of illicit drugs is high and
people on low incomes have to devote large amounts of time to securing money.
Everything else tends to fall by the wayside besides raising money and ‘‘scoring’.
People use a range of strategies to raise money but, initially, the most common
strategies are the use of credit cards and borrowing money from friends and relatives.
This signals the start of the second stage of the substance abuse pathway, which is
characterised by changes to existing social networks. Snow and Anderson (1993)
argued that the erosion of support networks, particularly friends and family, is:
Regarded as particularly critical in the determination of homelessness. A person
does not become homeless ... simply because he or she is an alcoholic, but because
these disabilities exhaust the patience or resources otherwise available in our social
networks. (Snow & Anderson, 1993, p. 256)
People who lose these vital social supports, or do not have them to start with, are
acutely vulnerable to homelessness.
Respondents told us that borrowing money strained friendships to breaking point.
Tony’s best friend tried to help but, eventually, ‘‘He said to me ...I only see you when
you want money. And it was true. I always made up lies to borrow money. Eventually
he stopped lending me money.’’
When existing friends would no longer assist, other friends and acquaintances were
approached. Tony said, ‘‘I tried everyone I could think of but no-one would lend me
money’’. Gradually, his friends stopped coming to see him as a result of his
continuing demands.
Names and extraneous details have been changed to preserve anonymity.
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Many substance abusers still relied on their families for support. Families typically
try to assist their children, but when children break promises it puts acute pressure on
many parents. Toby said that he ‘‘burnt my bridges with my family. I did some really
shitty things.’ Bert said, ‘‘One night when I was ‘off my face’ I fell over in the laundry.
I reached out for the sink and I ended up pulling the boiler over. That was it. My
father said ‘get out’.’’
Most families tried hard to help children who were in trouble, but when parents
were pushed too far many withdrew their support.
As established social networks collapsed, new networks started to form. This
signals the third stage of the substance abuse pathway. These networks were
dominated by others with substance abuse problems (Rice et al., 2005). Danny said
this ‘‘new crowd’’ were no longer ‘‘dabblers’’ (an occasional user) but were a ‘‘very
different crowd from those I met at drug parties’. John’s remark illustrates the highly
opportunistic nature of these friendships: ‘‘They were your friends, but really they’re
not your friends, because they’ve smacked money off you. If they were your real
friends, they wouldn’t give you that stuff.’’
Once the support of family and friends had collapsed, most people who had
substance abuse problems were at acute risk of homelessness. Toby ‘‘just wasn’t
getting the bills paid’’ because of his habit, whereas Tan’s worsening habit meant that
his housing hung by a slender thread: ‘‘ Sometimes you will only pay your board, you
know ...and if you don’t pay your board, you get kicked out, and that’s what
happens sometimes’’.
Most people who are at risk of homelessness report high levels of anxiety and
psychological distress at the prospect of losing their accommodation (van Doorn,
2005; Wong & Piliavin, 2001; Wong, 2002), but people with substance abuse
problems tended to ‘‘slide’’ into homelessness. This reflects the fact that many were
already connected to the drug scene and for most ‘‘feeding their habit’’ was the
priority. After losing his accommodation, John said, ‘‘I didn’t care ... It didn’t bother
me ... You know, I was already walking around with nowhere to go. I didn’t realise I
was one of them.’’
Substance Abuse as an Adaptation to Homelessness
Recently, more researchers have focused on substance abuse as adaptation. When
people are homeless, they adapt in order to survive. Although responses may vary
from person to person, using drugs is a common form of adaptation.
In the present study, 43% of the sample had substance abuse issues. Table 1 shows
that two-thirds (66%) developed problematic substance use after they became
homeless. Our data confirm that substance abuse is common among the homeless
population, but, for many people, substance abuse follows homelessness. Drug use is
an adaptive response to an unpleasant and stressful environment and drug use creates
new problems for many people.
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There are two common explanations as to why people become involved in
problematic substance use after they become homeless. First, some people take drugs
as a way to cope with or escape the harsh, oppressive environment that confronts
them (Neale, 2001). Toby said: ‘‘The only way I could deal with that place (a run
down boarding house) was to use drugs and I did use them’. David said that using
heroin helped him to forget about his troubles: ‘‘Using smack was a way for me to
hide ... You just hide away from everything ... You take your mind off everything
else because the one thing you’ve got to do each day is make sure you get your hit.’’
For Cameron, the situation was similar. Cameron had tried a range of drugs before
he became homeless, describing himself as an ‘‘on and off again’’ user. However, once
homeless, Cameron’s drug use worsened considerably as he tried to deal with his new
circumstances. It soon got to the point where substance abuse was a major issue in
Cameron’s life: ‘‘I didn’t realise how bad my drug use had got habit was
climbing and climbing. Everything was pretty much out of control at that point.’
The second reason for problematic substance use stems from increasing
involvement in the homeless subculture, where drug use is a common and accepted
social practice. Drug use is commonly a form of initiation into the homeless
subculture (Auerswald & Eyre, 2002; Fitzpatrick, 2000). Tess said she started to use
heroin ‘‘because everybody around me was using smack’’. Joan was more explicit
about the influence of her homeless peers: ‘‘Just peer pressure, I suppose. People
around me were doing it and I wanted to fit in.’
Many homeless people strive for a sense of ‘‘belonging somewhere’, particularly
those who experience homelessness when they are young. As Goffman (1961, p. 280)
noted, ‘‘Without something to belong to, we have no stable self ...Our sense of
being a person can come from being drawn into a wider social unit.’’
Through interaction with other people in similar situations, the homeless
subculture provides ‘‘an essentially non-stigmatising reference group and a source
of interpersonal validation’’ (Snow & Anderson, 1993, p. 173). By mixing with other
homeless people, some find a measure of support and security.
Involvement in the homeless subculture is particularly important for young people
who often lack a sense of belonging somewhere following the breakdown in their
family relationships. This involvement in the subculture is often accompanied by
initiation into substance use.
Table 2 shows that that 60% of our sample who had their first experience of
homelessness when they were 18 years of age or younger (teenagers) had
subsequently become involved in problematic substance use. In contrast, only 14%
Table 1 Substance Abuse Identified Before or After Homelessness
Substance abuse before homelessness 656 34
Substance abuse after homelessness 1,284 66
Total 1,940 100
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of those who had first experienced homelessness when they were 19 years or older
(adults) had subsequently developed substance abuse problems.
Involvement with the homeless subculture is a ‘‘double-edged sword’’ (Grigsby,
Baumann, Gregorich, & Roberts-Grey, 1990). On the one hand, associating with
other homeless people can provide a ‘‘refuge from the exclusion they suffer’’ (Rice et
al., 2005) and can suppress the insecurity typically associated with being homeless.
On the other hand, participation in the homeless subculture can lead to
entrenchment in the homeless population. This happens because many of the social
practices people learn in order to survive homelessness make it difficult for them to
get out of homelessness (Grigsby et al., 1990). Alexis had never injected drugs prior to
becoming homeless but she soon learnt: ‘‘I bought the smack from a girl who showed
me how to hit up ... she just gave it to me in bits ...That’s how I learned to inject
People who are long-term homeless often use boarding houses or squats. These are
dangerous places and drug use is sometimes the only link between residents. Palik
told us about an inner city boarding house:
I was more frightened in there than when I was on the streets. I was trembling
because there were all these big dudes ... There was nothing I could talk to them
about apart from drugs. The only thing we had in common was heroin.
Boarding houses provide easy access to drugs. Palik’s dealer lived in the same
boarding house.
Regardless of whether substance abuse precedes or follows homelessness, it
typically locks people into the homeless population. Table 3 uses three temporal
classifications (short-term, medium-term, and long-term homelessness) to demon-
strate that homeless people with substance abuse issues are more likely to get stuck in
the homeless population. Table 3 shows that 82% of people who had substance abuse
issues had been homeless for 12 months or longer. In contrast, only 50% of those who
had no substance abuse issues had been homeless for that long. When people have
substance abuse problems they become marginalised from mainstream institutions
and getting out of homelessness becomes more difficult.
Not only do people with substance abuse problems face barriers to getting out of
homelessness, but they also have difficulties remaining housed. Table 4 shows that
Table 2 Proportion of Respondents Developing Substance Abuse Issues Following
Homelessness According to Age when they First Became Homeless
Age at first homelessnes (years)
18 or younger
19 or older
% Respondents developing substance
abuse following homelessness
60 14 35
*Excludes 656 people who had substance abuse issues before they became homeless.
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76% of those who were substance abusers had experienced two or more periods of
homelessness. These people had attempted to return to secure accommodation, but
had become homeless again. Unless homeless people with substance abuse issues have
access to ongoing assistance, they often relapse and return to problematic substance
use (Milby, Schumacher, Wallace, Freedman, & Vuchinich, 2005) and subsequently
lose their accommodation.
This paper set out to investigate whether most people become homeless because of
problematic substance use problems or whether substance abuse typically occurs
later. We applied the social selection and social adaptation framework of Johnson
et al. (1997) and found that both approaches helped us understand the relationship
between substance abuse and homelessness. However, we found that the social
adaptation account was a better fit overall. Nearly 45% of our sample had substance
abuse issues, but two-thirds developed these problems after they had become
homeless. Next, we comment on three policy implications of these findings.
First, the data indicate that people who first experience homelessness when they are
18 years of age or under are more likely to develop substance abuse issues than people
who become homeless when aged 19 years or older. Of those who had become
homeless as teenagers, 60% had developed substance abuse issues. In contrast, of
those who had become homeless as adults, only 14% had become substance abusers.
For some homeless teenagers, substance use is a way of coping with the boredom and
Table 3 Duration of Homelessness According to Experience of Substance Abuse
No substance abuse
Substance abuse
Duration of homelessness
Short term
(B3 months)
31 7 20
Medium term
(311 months)
19 11 16
Long term
(12 months or longer)
50 82 64
Total 100% 100% 100%
Table 4 Proportion of Respondents who had two or more Episodes of Homelessness
According to Experience of Substance Abuse
No substance abuse
Substance abuse
% Respondents with two or more
episodes of homelessness
48 76 61
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frustration of their daily lives. For other young people, substance use is part of the
process of socialisation into the homeless subculture. The first policy challenge is how
to prevent young homeless people from engaging with the homeless subculture where
substance abuse often begins.
Most teenagers have their first experience of homelessness while they are still at
school (Crane & Brannock, 1996; O’Connor, 1989). It is widely recognised that
schools are sites for early intervention because it is easier to help homeless young
people when they are still at school and located in their local community
(Chamberlain & Mackenzie, 1998; Department of Family and Community Services,
2003; House of Representatives, 1995). Early intervention involves strategies that
assist homeless teenagers to reunite with their family or make the transition to
independent living. It is only when homeless students drop out of school and leave
behind their local ties that they are likely to get involved with the homeless subculture
where substance abuse is common (Hartwell, 2003, p. 484).
Second, we found that irrespective of whether substance use preceded or followed
homelessness, people with substance abuse problems tended to stay in the homeless
population longer than other homeless people. When this happens, these people’s
social networks start to change and include mainly homeless people (Rice et al.,
2005). Recent research suggests that ‘‘the removal of oneself from a lifestyle centred
on drug use, and the ability to adjust to a new lifestyle, is integral to recovery from
problematic drug use’’ (Rowe, 2002, p. 6). However, people who received assistance
for their drug problems often returned to emergency accommodation or boarding
houses where they were in contact with others who had substance abuse problems.
This maintains people’s exposure to drugs and increases the possibility that they will
relapse (Anderson, Shannon, Schyb, & Goldstein, 2002; Johnson et al., 2008).
Other people in recovery were rehoused in neighbourhoods where illegal drug
activity was high and this made it difficult for them to maintain abstinence
(Anderson et al., 2002). Policy makers and service providers have long recognised that
the desirable policy option is that people should be assisted into permanent housing
in communities where drug use is low (Milby et al., 2005). This may not be possible
at the present time because substance abuse is widespread in public housing estates
(Bessant et al., 2002) and there is also an acute shortage of public housing in most
cities. Given the constraints in the housing market are unlikely to change in the
foreseeable future, one policy alternative is to foster better links between state and
community housing providers and specialist clinical services. Research has shown
that a more integrated, holistic approach can reduce the prospect of relapse (Milby
et al., 2005; Padgett, Gulcur, & Tsemberis, 2006) and help fill the vacuum that often
‘‘accompanies the removal from an all consuming drug dependency’’ (Bessant et al.,
This highlights the third policy issue that relates to long-term support for people
who are rehoused. As we have seen, 76% of people with problematic substance use
issues had returned to conventional housing, but these tenancies had subsequently
failed (Table 4). Housing provides a stable base that is necessary to start the process of
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recovery but, on its own, the provision of housing is rarely sufficient. People in
recovery typically have a range of problems to resolve. Long-term homelessness and
substance abuse can have a devastating impact on people’s physical and psychological
health and their connectedness to mainstream society. For young people in recovery,
it often takes time to come to terms with the traumatic events that led to their
homelessness and substance abuse, and it is unrealistic to think that their recovery
will be achieved quickly. As Hartwell (2003, p. 498) noted, most people do not change
within ‘‘three, six, or nine months of substance use treatment’. Unless governments
fund ongoing support to help formerly homeless people with substance abuse
problems to remain housed, it is clear that some people will experience further
episodes of homelessness. When this happens, the costs to the individual, as well as to
the community, are high.
The relationship between problematic substance use and homelessness is complex
and there is a great deal of variation between individual cases. We have also pointed
to various limitations of our database and that relevant information may have been
missing from some case files.
According to Hartwell (2003, p. 476), the question of cause and consequence is
‘‘inherently misleading’. We agree that framing the debate in terms of cause is
problematic and underplays the complexity of people’s situation. However, a focus on
temporal sequence provides useful information on the role of substance abuse as a
trigger for homelessness and as an adaptation to homelessness. This research
confirms that a substantial minority of the homeless population have substance abuse
issues, but it challenges the view that substance abuse is the primary cause of
homelessness. For young people, homelessness often leads to substance abuse. Early
intervention strategies are the best way to prevent this from happening.
The authors thank the homeless people interviewed for the present study. The
authors also thank the staff at the Salvation Army Crisis Services (St Kilda, Vic.,
Australia) and HomeGround Services for their assistance. Thanks also to the
anonymous referees. Financial support for the research came from an Australian
Research Council grant (LP0560760).
Anderson, T., Shannon, C., Schyb, I., & Goldstein, P. (2002). Welfare reform and housing: Assessing
the impact to substance abusers. Journal of Drug Issues,32, 265296.
Auerswald, C., & Eyre, S. (2002). Youth homelessness in San Francisco: A life cycle approach. Social
Science and Medicine,54, 14971512.
Baum, A., & Burnes, D. (1993). Facing the facts about homelessness. Public Welfare,51,110.
Bessant, J., Coupland, H., Dalton, T., Maher, L., Rowe, J., & Watts, R. (2002). Heroin users, housing
and social participation: Attacking social exclusion through better housing. Melbourne:
Australian Housing and Urban Research Institute.
Burns, R. (1994). Introduction to research methods. Melbourne: Longman Cheshire.
354 G. Johnson & C. Chamberlain
Downloaded By: [RMIT University Library] At: 06:37 2 May 2009
Chamberlain, C. (1999). Counting the homeless: Implications for policy development. Canberra:
Australian Bureau of Statistics.
Chamberlain, C., & Johnson, G. (2001). The debate about homelessness. Australian Journal of Social
Chamberlain, C., & Mackenzie, D. (2003). Counting the homeless 2001. Canberra: Australian Bureau
of Statistics.
Coumans, M., & Spreen, M. (2003). Drug use and the role of homeless in the process of
marginalization. Substance Use & Misuse,38, 311338.
Crane, P., & Brannock, J. (1996). Homelessness among young people in Australia: Early intervention
and prevention. A report to the national youth affairs research scheme. Hobart: National
Clearing Housing for Youth Studies.
Culhane, D. (2005). Translating research into homelessness policy and practice: One perspective
from the United States. Parity,18, 19.
Fitzpatrick, S. (2000). Young homeless people. Basingstoke: MacMillan.
Fountain, J., & Howes, S. (2002). Home and dry? Homelessness and substance use in London. London:
National Additction Centre.
Ginzler, J., Cochran, B., Domenech-Rodriguez, M., Cauce, A., & Whitbeck, L. (2003). Sequential
progression of substance use among homeless youth: An empirical investigation of the
gateway theory. Substance Use & Misuse,38, 725758.
Glasser, I., & Zywiak, W. (2003). Homelessness and substance misuse: A tale of two cities. Substance
Use & Misuse,38, 551576.
Goffman, E. (1961). Asylumns: Essays on the social situation of mental patients and other inmates.
Harmondsworth: Penguin.
Grigsby, C., Baumann, D., Gregorich, S., & Roberts-Grey, C. (1990). Disaffiliation to entrenchment:
A model for understanding homelessness. Journal of Social Issues,46, 141156.
Hanover, Welfare Services (2006). Public perceptions. Melbourne: Hanover Welfare Services.
Hartwell, S. (2003). Deviance over the life course: The case of homeless substance abusers. Substance
Use & Misuse,38, 475502.
Hirst, C. (1989). Forced exit: A profile of the young and homeless in inner urban Melbourne.
Melbourne: The Salvation Army.
Horn, M. (2001). Homelessness and drugs: Links between experiences. Parity,14,812.
Johnson, G., Gronda, H., & Coutts, S. (2008). On the outside: Pathways in and out of homelessness.
Melbourne: Australian Scholarly Press.
Johnson, T., Freels, S., Parsons, J., & Vangeest, J. (1997). Substance abuse and homelessness: Social
selection or social adaptation. Addiction,92, 437445.
Jordon, A. (1995). An historical overview of homelessness, Parity,8,67.
Kemp, P., Neale, J., & Robertson, M. (2006). Homelessness among problems drug users: Prevalence,
risk factors and triggers events. Health and Social Care in the Community,14, 319328.
Keys, D., Mallett, S., & Rosenthal, D. (2006). Giving up on drugs: Homeless young people and self-
reported problematic drug use. Contemporary Drug Problems,33,6398.
Labov, W. (1997). Some further steps in narrative analysis. The Journal of Narrative and Life History.
Retrieved March 13, 2008, from
Mallett, S., Edwards, J., Keys, D., Myers, P., & Rosenthal, D. (2003). Disrupting stereotypes: Young
people, drug use and homelessness. Melbourne: Key Centre for Women’s Health in Society, The
University of Melbourne.
Mallett, S., Rosenthal, D., & Keys, D. (2005). Young people, drug use and family conflict: Pathways
into homelessness. Journal of Adolescence,28, 185199.
Milby, J., Schumacher, J., Wallace, D., Freedman, M., & Vuchinich, R. (2005). To house or not to
house: The effects of providing housing to homeless substance users in treatment. American
Journal of Public Health,95, 12591265.
Australian Social Work 355
Downloaded By: [RMIT University Library] At: 06:37 2 May 2009
Morrell-Bellai, T., Goering, P., & Boydell, K. (2000). Becoming and remaining homeless: A
qualitative investigation. Issues in Mental Health Nursing,21, 581604.
Neale, J. (1997). Homelessness and theory reconsidered. Housing Studies,12,4761.
Neale, J. (2001). Homelessness amongst drug users: A double jeopardy explored. The International
Journal of Drug Policy,12, 353369.
Neil, C., & Fopp, R. (1993). Homelessness in Australia: Causes and consequences. Melbourne: CSIRO
Division of Building Construction and Engineering: Victorian Ministerial Advisory
Committee on Homelessness and Housing.
O’Connor, I. (1989). Our homeless children: Their experiences. Sydney: Human Rights and Equal
Opportunity Commission.
Padgett, D., Gulcur, L., & Tsemberis, S. (2006). Housing first services for people who are homeless
with co-occurring serious mental illness and substance abuse. Research on Social Work,16,
Rice, E., Milburn, N., Rotheram-Borus, M. J., Mallett, S., & Rosenthal, D. (2005). The effects of peer
group network properties on drug use among homeless youth. American Behavioral Scientist,
48, 11021123.
Rowe, J. (2002). Survival strategies of the homeless and drug dependent. Don’t wander around in
your bare feet. The squalling experience, paper presented to the Housing, Crime and
Stronger Communities Conference, Melbourne.
Snow, D., & Anderson, L. (1993). Down on their luck: A study of street homeless people. Berkeley:
University of California Press.
Snow, D., Anderson, L., & Koegel, P. (1994). Distorting tendencies in research on the homeless.
American Behavioral Scientist,37, 461476.
Teesson, M., Hodder, T., & Buhrich, N. (2003). Alcohol and other drug use disorders among
homeless people in Australia. Substance Use & Misuse,38, 463474.
Timmer, D., Eitzen, D., & Talley, K. (1994). Paths to homelessness: Extreme poverty and the urban
housing crisis. Boulder: Westview Press.
van Doorn, L. (2005). Phases in the development of homelessness: A basis for better targeted service
interventions (pp. 1417). Homeless in Europe, Winter.
Victorian Homelessness Strategy. (2002). Action plan and strategic framework: Directions for
change. A collaborative approach to improving our response to homelessness. Melbourne:
Department of Human Services (Vic.).
Wong, I. (2002). Tracking change in psychological distress among homeless adults: An examination
of the effect of housing status. Health and Social Work,27, 262273.
Wong, I., & Piliavin, I. (2001). Stressors, resources and distress among homeless persons: A
longitudinal analysis. Social Science and Medicine,52, 10291042.
Zlotnick, C., Robertson, M., & Tam, T. (2002). Substance use and labor force participation among
homeless adults. American Journal of Drug and Alcohol Abuse,28,3753.
Zufferey, C., & Chung, D. (2006). Representations of homelessness in the Australian print media:
Some implications for social policy. Just Policy,42,3238.
356 G. Johnson & C. Chamberlain
Downloaded By: [RMIT University Library] At: 06:37 2 May 2009
... [27] Further, the relationship between homelessness and substance use is complex and bidirectional. [16,28] Substance abuse poses homeless individuals hard to rehabilitate to the society. [9,28,29] The Affordable Care Act Medicaid expansion has led to the improvement of health care access and coverage for homeless individuals, especially for those with mental health and addiction conditions, main contributors to substance use. ...
... [16,28] Substance abuse poses homeless individuals hard to rehabilitate to the society. [9,28,29] The Affordable Care Act Medicaid expansion has led to the improvement of health care access and coverage for homeless individuals, especially for those with mental health and addiction conditions, main contributors to substance use. [30][31][32] Our findings suggest that mental health conditions exist among one third of homeless patients, which is virtually the same as being reported by an earlier study based on the HCUP 10 state SIDs data in 2008. ...
... [36] Chronic homelessness is related to higher consumption rate of substance use. [28,37] Contemporary old homeless individuals, many of them being baby boomers, experienced the crack cocaine epidemic when they were young. [19] Children and young adult homeless individuals are known to be more tempted into substance use. ...
Full-text available
We aimed to examine trends and characteristics of substance use (opioid, cocaine, marijuana, and heroin) among hospitalized homeless patients in comparison with other hospitalized patients in 3 states. This was a cross-sectional study, based on the 2007 to 2015 State Inpatient Data of Arizona, Florida, and Washington (n = 32,162,939). Use of opioid, cocaine, marijuana, heroin, respectively, was identified by the International Classification of Diseases, 9th Revision. Multi-level multivariable regressions were performed to estimate relative risk (RR) and 95% confidence intervals (CI). Dependent variables were the use of substances (opioid, cocaine, marijuana, and heroin), respectively. The main independent variable was homeless status. The subgroup analysis by age group was also conducted. Homeless patients were associated with more use of opioid (RR [CI]), 1.23 [1.20–1.26], cocaine 2.55 [2.50–2.60], marijuana 1.43 [1.40–1.46], and heroin 1.57 [1.29–1.91] compared to other hospitalized patients. All hospitalized patients including those who were homeless increased substance use except the use of cocaine (RR [CI]), 0.57 [0.55–0.58] for other patients and 0.60 [0.50–0.74] for homeless patients. In all age subgroups, homeless patients 60 years old or older were more likely to be hospitalized with all 4 types of substance use, especially, cocaine (RR [CI]), 6.33 [5.81–6.90] and heroin 5.86 [2.08–16.52] in comparison with other hospitalized patients. Homeless status is associated with high risks of substance use among hospitalized patients. Homeless elderly are particularly vulnerable to use of hard drugs including cocaine and heroin during the opioid epidemics.
... Alcohol and drug dependence are the most common mental health issues among homeless populations in high-income countries, with rates of alcohol use disorder ranging from 5.5 to 71.7% and drug use disorder rates varying from 0 to 72.1% (Gutwinski et al., 2021). Substance use may precipitate entry into homeless by depleting an individual's social and economic resources (Johnson et al., 1997) or develop later as a coping mechanism to manage the stressors of homelessness (Johnson & Chamberlain, 2008). ...
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Homelessness has been associated with high levels of alcohol and other drug use, which has in turn been linked to social anxiety. The aim of the present study was to investigate homeless individuals’ experiences of social anxiety and substance use, their treatment history, and their therapeutic needs. Two focus groups were facilitated with fourteen participants. Participants were all male and aged between 27 and 63 years (M = 45.21, standard deviation, SD = 9.90). Thematic analysis identified four key themes: (1) longstanding difficulties with social anxiety and substance use; (2) mechanisms of social anxiety, substance use, and their interaction; (3) disenfranchisement with existing treatment options; and (4) needs for future treatment. Homeless individuals with social anxiety and histories of substance use reported experiencing these difficulties for several years, perpetuated by denial and/or misunderstanding. They reported that social anxiety and substance use were parallel, mutually reinforcing processes. Participants indicated that available substance use and social anxiety interventions were not fully satisfying and emphasised the importance of practical skills and an understanding therapeutic space.
... Many studies have discussed the relationship between substance abuse and homelessness. Sometimes substance abuse precedes homelessness but homelessness can also exacerbate the issue [4,29,30]. Higher healthcare costs among the homeless are mostly associated with diagnosed mental health disorders or substance abuse [31]. But disability status is different from other demographic variables; it is a developmental factor that can change from one homeless shelter stay to the next, and therefore, a potentially improvable factor. ...
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Objective: To identify determinants that contribute to the length of homeless shelter stay. Methods: We utilized a unique dataset from the Homeless Management Information Systems from Boston, Massachusetts, United States, which contains 44,197 shelter stays for 17,070 adults between Jan. 2014 and May 2018. Results: Our statistical analyses and regression model analyses show that factors that contribute to the length of a homeless shelter stay include being female, senior, disability, being Hispanic, or being Asian or Black African. A significant fraction of homeless shelter stays (76%) are experienced by individuals with at least one of three disabilities: physical disability, mental health issues, or substance use disorder. Recidivism also contributes to longer homeless shelter stays. Conclusion: The results suggest possible program and policy implications. Several factors that contribute to longer homeless shelter stay, such as gender, age, disability, race, and ethnicity, may have funding implications. Age may point to the need for early interventions. Disability is developmental and may benefit from treatment and intervention. Finally, we find that length of stay and recidivism are not independent, and may form a vicious cycle that requires additional investigation.
... The health inequities experienced by individuals who are deprived of housing are well recognised in existing literature, and include high rates of physical and cognitive conditions, mental illness and substance use disorders (Canadian Population Health Initiative, 2009;Fazel et al., 2014;Hwang, 2001;Public Health Agency of Canada, 2006). Existing studies emphasise that persons who experience homelessness and live with mental illness and substance use disorders have complex needs, which when left unmet, have the potential to perpetuate the cycle of homelessness, decrease housing stability and prolong social and mental health suffering (Fazel et al., 2014;Frankish et al., 2005;Johnson & Chamberlain, 2008;Somers et al., 2015). Individuals who experience homelessness and use substances are a diverse group, and there is a need to uncover their specific experiences and needs in order to support the development of solutions and tailor services appropriately. ...
Methamphetamine (MA) use among individuals who experience homelessness has tripled in recent years. This is a problematic trend given the harmful impacts of this substance on health and social well-being. While there is a large body of literature on the relationship between substance use and trauma, little is known about the scope of existing empirical literature exploring this topic related to MA use. Anecdotally, MA is frequently associated with violence and victimisation, which may be related to stigma associated with using MA. However, little is known about the scope of empirical literature exploring violence and victimisation in the lives of individuals who experience homelessness and use MA. We conducted a scoping review to fill this gap in existing literature using Arksey and O’Malley's methodological framework. Our search was conducted between January 2021 and March 2021 and was deployed in seven databases: Medline, Embase, CINAHL, PsycINFO, Sociological Abstracts, Nursing and Allied Health and AMED. Two independent raters screened 700 titles and abstracts after the removal of duplicates. A total of 54 articles were subjected to a full-text review and 20 articles met the inclusion criteria. We generated two themes: methamphetamine and victimisation and challenging behaviours. Six (30%) of the included articles explored MA use in relation to violence, while 18 (90%) explored experiences of victimisation among persons experiencing homelessness. Our findings highlight that individual who experience homelessness and use MA are particularly vulnerable to experiences of trauma. Though existing literature does acknowledge the challenging behaviour associated with MA use, only three existing studies demonstrated a relationship between MA use and physical violence. Research exploring the impacts of MA use on victimisation among persons who experience homelessness, and the development of interventions for managing challenging behaviours associated with MA use are needed.
... 11,35 Finally, unstable housing and interpersonal violence can give rise to SUDs, PTSD, and mental illnesses owing to the psychological stress and trauma they incur. 36,37 Few studies explicitly look at the relationship between interpersonal violence and psychosocial factors as an explanatory model for unstable housing in the Veteran population. A study of homelessness among male Veterans of the Vietnam war found that childhood interpersonal violence, mental illness, and SUD were risk factors for homelessness after discharge from military service. ...
Background Despite programs to address housing for Veterans, they continue to be at high risk of unstable housing. Interpersonal violence is also highly prevalent among Veterans and may contribute to unstable housing. Our study aimed to determine whether interpersonal violence was associated with unstable housing among Veterans, and how this association was influenced by common co-occurring conditions such as substance use and mental illness. Methods Veterans in the Mind Your Heart Study (N = 741) completed survey data on history of interpersonal violence and access to housing in the prior year. Interpersonal violence was defined as experiencing sexual violence, physical violence, or mugging/physical attack using the Brief Trauma Questionnaire. Multivariable models examined associations between interpersonal violence and unstable housing. Primary models were adjusted for age and sex. Potential explanatory factors were added in subsequent models, including marital status, education, income, substance use disorder, PTSD, and other mental illness. Results Veterans who had experienced interpersonal violence had almost twice the odds of unstable housing after adjustment for age and sex (AOR 1.9, 95% CI 1.2–3.0). This association was attenuated in the fully adjusted model including substance use, PTSD, and other mental illness, illustrating the interdependence of these factors (AOR 1.5, 95% CI 0.91–2.5). Subtypes of interpersonal violence were individually associated with increased odds of unstable housing after adjustment for age and sex (physical abuse AOR 1.7, 95% CI 1.2–2.5; mugging/physical attack AOR 1.8, 95% CI 1.2–2.7; sexual violence AOR 1.4, 95% CI 0.89–2.2), but were no longer significant in the fully adjusted model. Conclusions Previous experiences of interpersonal violence were associated with unstable housing among Veterans. Substance use, PTSD, and other mental illness played an important role in this relationship—highlighting the potential to improve health outcomes through trauma informed approaches that address mental health, substance use, and housing concurrently.
... Some studies on homeless people show that in 50% of cases these persons suffered from alcoholism before becoming homeless. In other 50% of cases, alcohol addiction developed after they became chronic homeless (Johnson and Chamberlain 2008). Alcohol addiction becomes an obstacle to employment and social integration and perpetuates the vicious circle of precariousness and exclusion. ...
To most, if not all, people active in the anti-corruption industry, this transaction that I witnessed has all the features of a bribe. The nurse could (or should) have refused the money since she had already a salary paid from the state and was not going to declare that extra income. But such a gesture has a different meaning in a hospital in London and Kyiv. In the latter context, doctors would work long hours for a salary that is a fraction of what they need to get to the end of the month.
Existing literature attests to water, sanitation, and hygiene (WASH) inequities among people experiencing homelessness (PEH) in the United States, but there is a dearth of research on such issues in rural areas. Homelessness is an emerging public health concern in rural areas where homelessness is on the rise, infectious disease outbreaks are becoming increasingly common, and PEH face unique WASH-related challenges compared to their urban counterparts. We conducted an exploratory study to understand the impacts of unmet WASH needs among rural PEH and their intersection with drug use through in-depth interviews (n = 10). Eligible participants were 18 years or older, lived in one of five Central Appalachian counties, and had experienced homelessness in the previous six months. Using thematic analysis, we identified factors that inhibit WASH access, and adverse health and well-being outcomes that result from unmet WASH needs. We also explore how WASH experiences compare among rural PEH who self-reported drug use to those who did not. Our findings revealed that factors at multiple levels inhibited WASH access, including stigma and place-based characteristics, which contributed to the adverse physical, mental, and emotional health of PEH. Comparisons between PEH who used drugs to those that did not revealed the intricate relationship between WASH, homelessness, and substance use in communities impacted by the opioid epidemic. Expanded WASH facilities that are safe and available with no prerequisites can address inadequate access among rural PEH and collaboration with harm reduction services may be advantageous to reach those who inject drugs.
Background Specialist homelessness practices remain the main primary care access point for many persons experiencing homelessness. Prescribing practices are poorly understood in this population. Objective This study aims to investigate prescribing of medicines to homeless persons who present to specialist homelessness primary care practices and compares the data with the general population. Setting Analyses of publicly available prescribing and demographics data pertaining to primary care in England. Methods Prescribing data from 15 specialist homelessness practices in England were extracted for the period 04/2019-03/2020 and compared with data from (a) general populations, (b) the most deprived populations, and (c) the least deprived populations in England. Main outcome measure Prescribing rates, measured as the number of items/1000 population in key disease areas. Results Data corresponding to 20,572 homeless persons was included. Marked disparity were observed in regards to prescribing rates of drugs for Central Nervous System disorders. For example, prescribing rates were 83-fold (mean (SD) 1296.7(1447.6) vs. 15.7(9.2) p = 0.033) items), and 12-fold (p = 0.018) higher amongst homeless populations for opioid dependence and psychosis disorders respectively compared to the general populations. Differences with populations in the least deprived populations were even higher. Prescribing medicines for other long-term conditions other than mental health and substance misuse was lower in the homeless than in the general population. Conclusions Most of the prescribing activities in the homeless population relate to mental health conditions and substance misuse. It is possible that other long-term conditions that overlap with homelessness are under-diagnosed and under-managed. Wide variations in data across practices needs investigation.
Background: Homelessness and substance use are intricately related, and both are prevalent among emergency department (ED) patients. This study examined the longitudinal association of substance use characteristics with future homeless shelter entry among ED patients with any drug use or unhealthy alcohol use. Methods: We present results from a longitudinal cohort study of public hospital ED patients who screened positive for drug use or unhealthy alcohol use and who were not homeless at their baseline (index) ED visit. The primary outcome was homeless shelter entry within 12 months of baseline, ascertained in city homeless shelter administrative data. Primary independent variables of interest were alcohol use severity (AUDIT), drug use severity (DAST-10), and types of drugs used, as reported on baseline survey questionnaires. Results: Analyses included 1,210 ED patients. By 12 months following the baseline ED visit, 114 (9.4%) had entered a homeless shelter. Among patients with the most severe problems related to drug use (DAST-10 score 9-10), 40.9% entered a shelter within 12 months. Past shelter use was the strongest predictor of future shelter entry; once adjusting for historic shelter use the relationship of AUDIT and DAST-10 scores with future shelter entry was no longer statistically significant in multivariable models. Conclusions: ED patients with past year drug use or unhealthy alcohol use had relatively high likelihood of future shelter entry. Risk for homelessness should be addressed in future interventions with this population. Findings illustrate the complexity of relationships between substance use and homelessness.
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With the current dire socioeconomic climate in most parts of the world, more and more people are being forced into the outskirts of society. As a result, homelessness is a growing concern globally, where these individuals are marginalised and face extreme cases of poverty and multiple victimisation. In response to this progressing social issue, a number of studies have been conducted to explore the various pathways into homelessness, with the majority focusing primarily on mental health and/or substance abuse as the main contributors. As the existing body of knowledge expanded, these pathways were later subdivided into individual risk factors (childhood adversity, mental illness and/or substance abuse) and structural factors (poverty, social exclusion and lack of affordable housing). However, these pathways are not limited to the aforementioned factors and also include low education and literacy levels, various physical health challenges and disabilities. As part of a broader study on the experiences of victimisation of the homeless, specific pathways were explored with a theoretical purposive sample of 17 homeless individuals who resided in shelters located in the Free State and Northern Cape provinces of the Republic of South Africa. The data was collected by means of semi-structured interviews and analysed and presented utilising common themes drawn from the individual narratives of the participants. The pathways identified in the study included, but are not limited to childhood adversity, poverty/unemployment; domestic violence; and family conflict. It therefore becomes imperative to identify and better understand these pathways, in order to create and implement strategies uniquely designed for this marginalised population in an attempt to reduce and ultimately prevent this local and global social issue.
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Information on homelessness form the 2006 Census
Numerous studies have revealed high levels of drug-taking among young people experiencing homelessness. This article draws upon 40 in-depth interviews carried out as part of a five-year longitudinal study of homeless young people (Project i). It is noteworthy that almost all of those who identified their drug use as problematic gave up or reduced their level of use without treatment or professional assistance during the period of the study. The interviews provided insight into the way in which some young people experiencing homelessness view their drug use and the actions they take in light of these understandings. Here we report their stated reasons for giving up or reducing usage and identify some commonalities that may have impacted on the outcomes.
Three definitions of homelessness which have been influential in Australia may be categorised as the literal, the subjectivist and the cultural. The literal definition equates homelessness with 'rooflessness'. The subjectivist definition attempts to establish 'homelessness' by asking people about the adequacy of their accommodation. The cultural definition argues that homelessness is an objective category which is not dependent on people's perceptions. From examining the usefulness of the three definitions in relation to a large body of data collected at an agency providing services for homeless people, we may contend that homelessness is best treated as a concept like poverty, which should be measured objectively and not depend on people's perceptions.
Overview Understanding Homelessness: Industrial and Urban Decline The Root Causes of Homelessness in American Cities Paths To Homelessness The Old Homeless: Sam Sheldon and Henry Walsh Work Versus WelfareA False Choice: Sue Jackson The Economic Marginality of Young Families: Sara, Dave, Elizabeth, and Joshua Left Behind in a De-industrialized, Low-Wage Economy: Bob and Nancy Shagford and Their Children Eviction: Debbie Jones and Her Children Social Service Bureaucracy and Homelessness: Diane Moore Runaway and Throwaway Teens: Jeffrey Giancarlo A Black Teenage Single Mother and Her Son: Michelle and Andre Battered Women and Homelessness: Barbara Evans Conclusion The Complex and Simple Reality of Homelessness Making Homelessness Go Away: Politics and Policy
Social workers have an important role in questioning how social problems such as homelessness are represented in public discourse. Using Carol Bacchi's policy analysis framework, this paper analyses representations of homelessness and service provision in the Australian print media, by examining assumptions underlying these representations, gaps and silences; the effects of these representations; and how these can be defended and disrupted. The study found that print media representations of people can reinforce deep-seated community values that maintain unequal gender and power relations, which has implications for social worker advocacy.
Theory will not directly explain the development of policy and provision for homeless people, but it is an important consideration and one deserving of careful attention. In the UK, however, homelessness has often been explained simplistically and somewhat atheoretically as either a housing or a welfare problem, caused either by structural or by individual factors. Likewise, homeless people have been frequently classified as either deserving or undeserving. Such dualistic explanations are less than adequate and any policy and provision influenced by them will, consequently, also likely be less than optimal. Accordingly, this paper explores the potential of alternative theoretical perspectives (feminism, post‐structuralism, postmodernism, structuration and critical theory) for increasing our understanding of homelessness and so potentially improving policy and provision for homeless people in the future.