Article

Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration

Authors:
  • US Department of Veterans Affairs; Philadelphia VAMC
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Abstract

Objective: To determine the prevalence of homelessness and risk for homelessness among veterans with opioid use disorder initiating treatment. Setting: Addiction treatment programs operated by the US Department of Veterans Affairs (VA). Participants: All veterans initiating treatment with methadone or buprenorphine for opioid use disorder between October 1, 2013 and September 30, 2014 (n = 2,699) who were administered the VA's national homelessness screener. Main outcome measures: Self-reported homelessness or imminent risk of homelessness. Results: The prevalence of homelessness was 10.2 percent and 5.3 percent were at risk for homelessness. Compared to male veterans, women veterans were less likely to report homelessness (8.9 percent vs 10.3 percent) but more likely to be at risk (11.8 percent vs 4.9 percent). By age group, veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and veterans aged 45-54 and 55-64 years most frequently reported risk for homelessness (6.5 and 6.8 percent, respectively). Conclusions: The prevalence of homelessness in this population is approximately 10 times that of the general veteran population accessing care at VA. Screening identified a substantial number of veterans who could benefit from VA housing assistance and had not received it recently. Programs to address veteran homelessness should engage with veterans seeking addiction treatment. Integration of homelessness services into addiction treatment settings may, in turn, improve outcomes.

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... Of the sixty included studies, twenty-seven reported on opioid use treatment access and engagement among PEH (Amodeo et al., 2004;Bachhuber et al., 2015;Bauer et al., 2016;Corsi et al., 2007;Daniulaityte et al., 2019;Deck and Carlson, 2004;Dunn et al., 2019;Englander et al., 2020;Eyrich-Garg et al., 2008;Hoffman et al., 2019;Kelly et al., 2018;Krawczyk et al., 2020;Krull et al., 2011;Lundgren et al., 2003;Masson et al., 2002;Midboe et al., 2019;Nyamathi et al., 2004;Patel et al., 2020;Reynoso-Vallejo et al., 2008;Rivers et al., 2006;Robbins et al., 2010;Royse et al., 2000;Shah et al., 2000;Simon et al., 2017;Timko et al., 2016;Upshur et al., 2018;Van Ness et al., 2004). While most were conducted among general populations of people who use opioids, five evaluated characteristics of treatment engagement exclusively among homeless-experienced populations (Bauer et al., 2016;Midboe et al., 2019;Nyamathi et al., 2004;Robbins et al., 2010;Upshur et al., 2018). ...
... A retrospective analysis found that PEH were less likely to have received OAT in the context of outpatient treatment admissions for OUD (Krawczyk et al., 2020). Moreover, the prevalence of homelessness among veterans initiating methadone or buprenorphine treatment was only 10.2 % in 2012 (Bachhuber et al., 2015), despite 34.6 % of veterans with OUD being homeless in the following two years (Iheanacho et al., 2018). PEH were also less likely to receive OAT than housed individuals in detoxification settings (Dunn et al., 2019), though they were more likely to receive XR-NTX than OAT and no treatment in a sample of veterans in 2012 (Kelly et al., 2018). ...
Article
Background The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 2019 coronavirus disease pandemic. Existing, evidence-based treatment options for opioid use disorder (OUD) are broadly underutilized, particularly by people experiencing homelessness (PEH). PEH are also more likely to misuse and overdose on opioids. To better understand current gaps and disparities in OUD treatment experienced by PEH and efforts to address them, we synthesized the literature reporting on the intersection of housing status and OUD treatment. Methods We conducted a scoping review of the literature from the electronic databases MEDLINE, Embase, PsycINFO, and Web of Science Core Collection. We included studies describing treatment-related outcomes specific to PEH and articles assessing OUD treatment interventions tailored to this population. Relevant findings were compiled via thematic analysis and narratively synthesized. Results We included 60 articles, including 43 descriptive and 17 intervention-focused studies. These studies demonstrated that PEH experience more barriers to OUD treatment than their housed counterparts and access inpatient and detoxification treatment more commonly than pharmacotherapy. However, the reviewed literature indicated that PEH have similar outcomes once engaged in pharmacotherapy. Efficacious interventions for PEH were low-barrier and targeted, with housing interventions also demonstrating benefit. Conclusions PEH have diminished access to evidence-based OUD treatment, particularly medications, and require targeted approaches to improve engagement and retention. To mitigate the disproportionate opioid-related morbidity and mortality PEH experience, innovative, flexible, and interdisciplinary OUD treatment models are necessary, with housing support playing an important role.
... We did not account for stimulant use as our data focused on 2016, likely preceding this "fourth wave." Lastly, homelessness is a major problem among patients with OUD, which could affect discharge decisions and access to PAC facilities and could lengthen hospital stays [51][52][53]. We sought to adjust for this by running a sensitivity analysis using homelessness as a covariate as described above, which did not significantly affect our results. ...
Article
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Background Patients with opioid use disorder (OUD) who are hospitalized for serious infections requiring prolonged intravenous antibiotics may face barriers to discharge, which could prolong hospital length of stay (LOS) and increase financial burden. We investigated differences in LOS, discharge disposition, and charges between hospitalizations for serious infections in patients with and without OUD. Methods and findings We utilized the 2016 National Inpatient Sample—a nationally representative database of all discharges from US acute care hospitals. The population of interest was all hospitalizations for infective endocarditis, epidural abscess, septic arthritis, or osteomyelitis. The exposure was OUD, and the primary outcome was LOS until discharge, assessed by using a competing risks analysis to estimate adjusted hazard ratios (aHRs). Adjusted odds ratio (aOR) of discharge disposition and adjusted differences in hospital charges were also reported. Of 95,470 estimated hospitalizations for serious infections (infective endocarditis, epidural abscess, septic arthritis, and osteomyelitis), the mean age was 49 years and 35% were female. 46% had Medicare (government-based insurance coverage for people age 65+ years), and 70% were non-Hispanic white. After adjustment for potential confounders, OUD was associated with a lower probability of discharge at any given LOS (aHR 0.61; 95% CI 0.59–0.63; p < 0.001). OUD was also associated with lower odds of discharge to home (aOR 0.38; 95% CI 0.33–0.43; p < 0.001) and higher odds of discharge to a post-acute care facility (aOR 1.85; 95% CI 1.57–2.17; p < 0.001) or patient-directed discharge (also referred to as “discharge against medical advice”) (aOR 3.47; 95% CI 2.80–4.29; p < 0.001). There was no significant difference in average total hospital charges, though daily hospital charges were significantly lower for patients with OUD. Limitations include the potential for unmeasured confounders and the use of billing codes to identify cohorts. Conclusions Our findings suggest that among hospitalizations for some serious infections, those involving patients with OUD were associated with longer LOS, higher odds of discharge to post-acute care facilities or patient-directed discharge, and similar total hospital charges, despite lower daily charges. These findings highlight opportunities to improve care for patients with OUD hospitalized with serious infections, and to reduce the growing associated costs.
... In addition to the role of the provider, the type of clinic where a Veteran responds to the HSCR also appears to be important, although it is difficult to interpret this finding given that the category of "other" has the only significant effect. Analyses of HSCR data have found that rates of positive screens are significantly higher in specialty clinicsparticularly for mental health and substance use (Montgomery 2016) as well as methadone maintenance (Bachhuber et al. 2015)-than in primary care clinics, and providers who participated in this study suggest that psychiatrists are often better connected with resources. Similarly, providers in specialty clinics may have more experience working with patients with higher social needs and may therefore be more experienced at responding to Veterans' needs when they screen positive for housing instability. ...
Article
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This study aims to explore the relationship between the context of screening for housing instability and Veterans’ access to services, with the goal of ensuring effective processes to address housing instability among Veterans. This study used administrative data from 100,022 Veterans’ electronic medical records and qualitative data collected during in-depth interviews with 22 health care providers and six Homeless Program staff. A mixed effects logistic regression assessed the relationship between Veterans’ screening experiences and connection with services; qualitative data were analyzed using a grounded theory approach to present providers’ reflections on administering screening for housing instability and responding to Veterans’ positive screens with needed resources. We observed a significant relationship between providers’ roles and location of screening with patients’ timely linkage with services. Providing additional training related to how to conduct the screen and provide required resources, shifting screening responsibilities to providers with more flexibility to address these needs, and embedding supportive services in the care team may improve post-screening linkage with services.
... Opioid use disorder (OUD) is associated with significant societal, physical, psychological, and economic burden (Bachhuber, Roberts, Metraux, & Montgomery, 2015;D'Onofrio et al., 2015;Fisher et al., 2014;Han et al., 2017;Stein et al., 2017). For people seeking treatment for OUD, medication-assisted treatment with buprenorphine, methadone, or naltrexone may be an option. ...
Article
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Introduction: The physical, social, psychological, and economic burden of opioid use disorder (OUD) is substantial. As of the year 2019, the predominant focus of OUD research was outcomes such as retention and abstinence. We report herein the effects of extended-release buprenorphine (BUP-XR), the first FDA-approved subcutaneously injected, monthly treatment for OUD, on patient-centered outcomes. Materials and methods: Patient-centered outcomes were collected during an open-label safety study of participants with OUD (NCT# 02510014) evaluating BUP-XR. Measures collected during the study included the EQ-5D-5L, SF-36v2, Treatment Effectiveness Assessment (TEA), Addiction Severity Index-Lite (ASI-Lite), employment/insurance status questionnaire, and Medication Satisfaction Questionnaire (MSQ). Changes from baseline to end of study week 49 were analyzed using mixed models for repeated measures. "Baseline" was defined as the value collected prior to the first BUP-XR injection. Results presented are for those participants who initiated treatment on BUP-XR during the open-label study and were eligible to receive up to 12 injections. Results: Four hundred twelve participants were included in analyses; 206 participants discontinued BUP-XR prematurely. Mean EQ-5D-5L scores remained stable from baseline to end of study. Statistically significant improvements from baseline to end of study were noted for the SF-36v2 mental component summary score (difference = 5.0, 95%CI: 3.5-6.5) and 7 of 8 domain scores (P < .05 for all comparisons); the SF-36v2 physical component summary remained stable from baseline to end of study. The TEA total score (difference = 9.3 points, 95%CI: 8.0-10.5) and 4 of 4 domain scores (difference = 2-3 points per domain) significantly improved from baseline to end of study. Significant improvements (P < .05 for all comparisons) on the ASI-Lite were seen for all problem areas except alcohol use from baseline to end of study. Employment rate increased 7% whereas health insurance status remained stable from baseline to end of study. Medication satisfaction measured using the MSQ was >88% at end of study. Conclusions: Treatment with BUP-XR monthly injections for up to 12 months in this cohort of treatment-seeking individuals with OUD led to positive PCOs and high treatment satisfaction, which correspond to personal recovery.
Article
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This study examined temporal relationships between relative onsets of mental illness and homelessness in a cross-sectional study of 900 homeless people compared with a matched, never-homeless sample from the Epidemiologic Catchment Area study. All psychiatric disorders preceded homelessness in the majority. Only one disorder, alcohol use disorder (in men only), had significantly earlier onset in homeless subjects. Regarding number of symptoms or earlier age of onset of psychiatric disorders, earlier onset of homelessness was associated with several diagnoses: schizophrenia, major depression, generalized anxiety disorder, alcohol and drug use disorders, and antisocial personality. In multiple regression models, history of dysfunctional family background and maternal psychiatric illness were also associated with earlier onset of homelessness, whereas education was protective. Chronicity of homelessness was associated with number of symptoms of alcohol use disorder and earlier age of onset of drug use disorder, presence and number of symptoms of schizophrenia and antisocial personality, and earlier onset of major depression and conduct disorder. In multiple regression models, more education, but not family background problems, was associated with shorter lifetime duration of homelessness. These findings provide information relevant to the roles of mental illness and personal vulnerability factors in the onset and chronicity of homelessness.
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To determine predictors of injection drug use cessation and subsequent relapse among a cohort of injection drug users (IDUs). IDUs in Baltimore, MD were recruited through community outreach in 1988-1989. Among IDUs with at least three follow-up visits, parametric survival models for time to injection cessation (>or=6 months) and subsequent relapse were constructed. Of 1327 IDUs, 94.8% were African American, 77.2% were male, median age was 34 years, and 37.7% were HIV-infected. Among 936 (70.5%) subjects who ceased injection, median time from baseline to cessation was 4.0 years. Three-quarters subsequently resumed injection drug use, among whom median time to relapse was 1.0 year. Factors independently associated with a shorter time to cessation were: age <30 years, stable housing, HIV seropositivity, methadone maintenance treatment, detoxification, abstinence from cigarettes and alcohol, injecting less than daily, not injecting heroin and cocaine together, and not having an IDU sex partner. Factors independently associated with shorter time to injection relapse were male gender, homelessness, HIV seropositivity, use of alcohol, cigarettes, non-injection cocaine, sexual abstinence and having a longer time to the first cessation. This study provides strong support for targeting cessation efforts among young IDUs and severely dependent, unstably housed, and HIV-infected individuals.
Longitudinal predictors of injection cessation and subsequent relapse among a cohort of injection drug users in
  • N G Shah
  • N Galai
  • D D Celentano
Shah NG, Galai N, Celentano DD, et al. : Longitudinal predictors of injection cessation and subsequent relapse among a cohort of injection drug users in Baltimore, MD, 1988-2000. Drug Alcohol Depend. 2006; 83: 147-156. [PubMed: 16364568]