Harm reduction treatment for smoking (HaRT-S): findings from a single-arm pilot study with smokers experiencing chronic homelessness.

Background: Smoking prevalence and mortality is 5 times higher for the chronically homeless versus general population. Unfortunately, traditional smoking cessation treatment does not optimally engage this population. In a preliminary study, smokers experiencing chronic homelessness suggested providers avoid giving advice to quit and instead use a more compassionate, nonjudgmental style to discuss a broader menu of patient-driven options, including safer nicotine use. Most had negative perceptions of smoking cessation medications; however, 76% expressed interest in a switchover to electronic nicotine delivery systems (ENDS). Methods: Using a community-based participatory research approach, we codeveloped harm-reduction treatment for smoking (HaRT-S) together with people with lived experience of chronic homelessness and smoking and a community-based agency that serves them. In HaRT-S, interventionists embody a compassionate, advocacy-oriented "heart-set" and deliver manualized components: a) participant-led tracking of smoking-related outcomes, b) elicitation of harm-reduction goals and progress made toward them, c) discussion of relative risks of nicotine delivery systems, and d) distribution and instructions on use of safer nicotine products. We then conducted a single-arm, 14-week pilot of HaRT-S (N = 44). Results: Participants rated procedures "totally acceptable/effective," which was reflected in 26% overrecruitment within a 4-month period and 70% retention at the 14-week follow-up. For each week in the study, participants experienced an 18% increase in odds of reporting 7-day, biochemically verified, point-prevalence abstinence. All participants reporting abstinence used ENDS. Participants evinced reductions in cigarette dependence (-45%), frequency (-29%), and intensity (-78%; ps < .05). Participants who used ENDS experienced an additional 44% reduction in smoking intensity and a 1.2-point reduction in dependence compared to participants who did not. Conclusions: Harm-reduction counseling plus ENDS shows promise for smokers experiencing chronic homelessness. Randomized controlled trials are needed to establish the efficacy of this approach in decreasing smoking-related harm and improving health-related quality of life for this marginalized and disproportionately affected population.

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder.

BACKGROUND: People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition. METHODS: People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies. RESULTS: Compared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12). CONCLUSION: A low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.

Extended-release naltrexone and harm reduction counseling for chronically homeless people with alcohol dependence.

BACKGROUND: Abstinence-based alcohol interventions are minimally desirable to and effective for chronically homeless individuals with alcohol dependence who have multimorbidity and high publicly funded service utilization and associated costs. Lower-barrier, patient-centered combined pharmacobehavioral interventions may more effectively treat this population. Harm reduction counseling involves a nonjudgmental, empathic style and patient-driven goal setting that requires neither abstinence nor use reduction. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving, is safe and effective for active drinkers, and may thereby support harm reduction goal setting. The aims of this 12-week, single-arm pilot were to initially document some aspects of feasibility, acceptability, and alcohol outcomes following XR-NTX administration and harm reduction counseling for chronically homeless individuals with alcohol dependence. METHODS: Participants were currently/formerly chronically homeless, alcohol-dependent individuals (N = 31) from 2 community-based agencies in the US Pacific Northwest. Measures included self-reported alcohol craving, quantity/frequency, problems, and biomarkers (ethyl glucuronide [EtG], liver transaminases). XR-NTX and harm reduction counseling were administered monthly over the 3-month treatment course. RESULTS: Of the 45 individuals approached, 43 were interested in participation. The first injection was received by 31 participants, and 24 complied with all study procedures. Participants reported the treatment was acceptable. Participants evinced decreases in alcohol craving (33%), typical (25%) and peak (34%) use, frequency (17%), problems (60%), and EtG from the baseline to the 12-week follow-up (Ps < .05). CONCLUSIONS: XR-NTX and harm reduction counseling are promising means of supporting reductions in alcohol use and alcohol-related harm among chronically homeless, alcohol-dependent individuals.

Harm reduction with pharmacotherapy for homeless people with alcohol dependence: protocol for a randomized controlled trial.

BACKGROUND: Interventions requiring abstinence from alcohol are neither preferred by nor shown to be highly effective with many homeless individuals with alcohol dependence. It is therefore important to develop lower-threshold, patient-centered interventions for this multimorbid and high-utilizing population. Harm-reduction counseling requires neither abstinence nor use reduction and pairs a compassionate style with patient-driven goal-setting. Extended-release naltrexone (XR-NTX), a monthly injectable formulation of an opioid receptor antagonist, reduces craving and may support achievement of harm-reduction goals. Together, harm-reduction counseling and XR-NTX may support alcohol harm reduction and quality-of-life improvement. AIMS: Study aims include testing: a) the relative efficacy of XR-NTX and harm-reduction counseling compared to a community-based, supportive-services-as-usual control, b) theory-based mediators of treatment effects, and c) treatment effects on publicly funded service costs. METHODS: This RCT involves four arms: a) XR-NTX+harm-reduction counseling, b) placebo+harm-reduction counseling, c) harm-reduction counseling only, and d) community-based, supportive-services-as-usual control conditions. Participants are currently/formerly homeless, alcohol dependent individuals (N=300). Outcomes include alcohol variables (i.e., craving, quantity/frequency, problems and biomarkers), health-related quality of life, and publicly funded service utilization and associated costs. Mediators include 10-point motivation rulers and the Penn Alcohol Craving Scale. XR-NTX and harm-reduction counseling are administered every 4weeks over the 12-week treatment course. Follow-up assessments are conducted at weeks 24 and 36. DISCUSSION: If found efficacious, XR-NTX and harm-reduction counseling will be well-positioned to support reductions in alcohol-related harm, decreases in costs associated with publicly funded service utilization, and increases in quality of life among homeless, alcohol-dependent individuals.

Housing retention in single-site housing first for chronically homeless individuals with severe alcohol problems.

OBJECTIVES: We studied housing retention and its predictors in the single-site Housing First model. METHODS: Participants (n = 111) were chronically homeless people with severe alcohol problems who lived in a single-site Housing First program and participated in a larger nonrandomized controlled trial (2005-2008) conducted in Seattle, Washington. At baseline, participants responded to self-report questionnaires assessing demographic, illness burden, alcohol and other drug use, and psychiatric variables. Housing status was recorded over 2 years. RESULTS: Participants were interested in housing, although a sizable minority did not believe they would be able to maintain abstinence-based housing. Only 23% of participants returned to homelessness during the 2-year follow-up. Commonly cited risk factors--alcohol and other drug use, illness burden, psychiatric symptoms, and homelessness history--did not predict resumed homelessness. Active drinkers were more likely to stay in this housing project than nondrinkers. CONCLUSIONS: We found that single-site Housing First programming fills a gap in housing options for chronically homeless people with severe alcohol problems.

Exposure to project-based Housing First is associated with reduced jail time and bookings.

BACKGROUND: Project-based Housing First (HF) programs provide immediate, permanent, low-barrier, nonabstinence-based supportive housing to chronically homeless people within a single housing project. Previous studies have shown project-based HF is associated with 6-month reductions in jail time (Larimer et al., 2009), and that people with criminal histories are able to maintain their housing in supportive housing, such as project-based HF (Malone, 2009; Tsai & Rosenheck, 2012). This study aimed to extend these findings to document the criminal histories of project-based HF residents and to test the associations among exposure to project-based HF, criminal histories and jail time over a 2-year follow-up. METHODS: Participants (N = 95) were chronically homeless individuals with severe alcohol problems who moved into project-based HF. Measures included administrative data on criminal history, project-based HF exposure, and jail days and bookings for two-years prior to and subsequent to move into project-based HF. RESULTS: The majority of all past criminal convictions were misdemeanors (91.3%). Further, criminal convictions did not predict participants' housing retention in project-based HF. Months of project-based HF exposure - not prior criminal histories - predicted significant decreases in jail days and bookings from the two years prior and subsequent to participants' move into HF. CONCLUSIONS: Findings suggest that participants' criminal histories primarily reflect "symptoms" of homelessness rather than threats to public safety. Further, the extent of participants' criminal histories was not associated with subsequent jail time or housing attrition. Although causation cannot be implied, these findings show that the amount of time spent in project-based HF is associated with decreased jail time for up to two years following initial HF exposure.

Motivation to change and treatment attendance as predictors of alcohol-use outcomes among project-based Housing First residents.

Collins et al. (2012) indicated that time spent in a project-based Housing First (HF) intervention was associated with improved two-year alcohol-use trajectories among chronically homeless individuals with alcohol problems. To explore potential correlates of these findings, we tested the relative prediction of alcohol-use outcomes by motivation to change (MTC) and substance abuse treatment attendance. Participants (N=95) were chronically homeless individuals with alcohol problems receiving a project-based HF intervention in the context of a larger nonrandomized controlled trial (Larimer et al., 2009). Participants were interviewed regularly over the two-year follow-up. Treatment attendance and MTC were measured using items from the Addiction Severity Index and the SOCRATES, respectively. Alcohol-use outcomes included alcohol quantity, problems and dependence. Generalized estimating equation modeling indicated that MTC variables and not treatment attendance consistently predicted alcohol-use outcomes over the two-year follow-up. Findings suggest that the importance of motivation to change may outweigh treatment attendance in supporting alcohol behavior change in this population.

Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories.

OBJECTIVES: Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use. METHODS: A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records. RESULTS: Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes. CONCLUSIONS: Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.

Where harm reduction meets housing first: exploring alcohol's role in a project-based housing first setting.

BACKGROUND: Housing first (HF) programmes provide low-barrier, nonabstinence-based, immediate, supportive and permanent housing to chronically homeless people who often have co-occurring substance-use and/or psychiatric disorders. Project-based HF programmes offer housing in the form of individual units within a larger housing project. Recent studies conducted at a specific project-based HF programme that serves chronically homeless individuals with alcohol problems found housing provision was associated with reduced publicly funded service utilisation, decreased alcohol use, and sizable cost offsets. No studies to date, however, have qualitatively explored the role of alcohol use in the lives of residents in project-based HF. METHODS: We collected data in a project-based HF setting via naturalistic observation of verbal exchanges between staff and residents, field notes taken during staff rounds, and audio recorded staff focus groups and resident interview sessions. Qualitative data were managed and coded using a constant comparative process consistent with grounded theory methodology. The goal of the analysis was to generate a conceptual/thematic description of alcohol's role in residents' lives. RESULTS: Findings suggest it is important to take into account residents' motivations for alcohol use, which may include perceived positive and negative consequences. Further, a harm reduction approach was reported to facilitate housing attainment and maintenance. Residents and staff reported that traditional, abstinence-based approaches are neither desirable nor effective for this specific population. Finally, elements of the moral model of alcohol dependence continue to pervade both residents' views of themselves and the community's perceptions of them. CONCLUSIONS: Findings suggest it is necessary to set aside traditional models of alcohol use and approaches to better understand, align with, and address this population's needs. In doing so, we might gain further insights into how to enhance the existing project-based HF approach by applying more tailored, alcohol-specific, harm reduction interventions.

Exploring transitions within a project-based Housing First setting: qualitative evaluation and practice implications.

The Housing First (HF) approach is a model of housing that entails the provision of immediate, permanent, low-barrier, supportive housing to chronically homeless individuals either in separate apartments within a larger community (known as scattered-site HF) or in a single building (known as project-based HF). One recent innovation is the application of project-based HF with chronically homeless individuals with alcohol problems. Although initial studies have shown its effectiveness, there is currently no research on residents' and staff 's experiences living and working in a project-based HF program. The purpose of this article was to document these experiences and highlight strengths and challenges of project-based HF programs. Using data collected from naturalistic observations, agency documentation, one-on-one resident interviews, and a staff focus group, we delineated transitional periods, including moving into project-based HF, community-building, managing day-to-day, and transitions from project-based HF. Findings are interpreted to help health care policymakers and providers envision the role of project-based HF in comprehensive public health efforts and to integrate lessons learned into their own clinical practice.

Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.

CONTEXT: Chronically homeless individuals with severe alcohol problems often have multiple medical and psychiatric problems and use costly health and criminal justice services at high rates. OBJECTIVE: To evaluate association of a "Housing First" intervention for chronically homeless individuals with severe alcohol problems with health care use and costs. DESIGN, SETTING, AND PARTICIPANTS: Quasi-experimental design comparing 95 housed participants (with drinking permitted) with 39 wait-list control participants enrolled between November 2005 and March 2007 in Seattle, Washington. MAIN OUTCOME MEASURES: Use and cost of services (jail bookings, days incarcerated, shelter and sobering center use, hospital-based medical services, publicly funded alcohol and drug detoxification and treatment, emergency medical services, and Medicaid-funded services) for Housing First participants relative to wait-list controls. RESULTS: Housing First participants had total costs of $8,175,922 in the year prior to the study, or median costs of $4066 per person per month (interquartile range [IQR], $2067-$8264). Median monthly costs decreased to $1492 (IQR, $337-$5709) and $958 (IQR, $98-$3200) after 6 and 12 months in housing, respectively. Poisson generalized estimating equation regressions using propensity score adjustments showed total cost rate reduction of 53% for housed participants relative to wait-list controls (rate ratio, 0.47; 95% confidence interval, 0.25-0.88) over the first 6 months. Total cost offsets for Housing First participants relative to controls averaged $2449 per person per month after accounting for housing program costs. CONCLUSIONS: In this population of chronically homeless individuals with high service use and costs, a Housing First program was associated with a relative decrease in costs after 6 months. These benefits increased to the extent that participants were retained in housing longer.

Assessing criminal history as a predictor of future housing success for homeless adults with behavioral health disorders.

OBJECTIVE: Homeless adults with serious mental illnesses and chronic substance abuse problems have few housing options, a problem compounded when a criminal background is present. This study compared the criminal backgrounds and other characteristics of homeless individuals who succeeded in housing (retained housing continuously for two years) and those who failed in housing. METHODS: The study population consisted of homeless adults with behavioral health disorders who moved into supportive housing between January 1, 2000, and June 30, 2004, regardless of criminal background. Data about criminal history and other characteristics were extracted from existing records and analyzed for associations with housing success. Chi square tests and logistic regression analysis were used to find characteristics predictive of subsequent housing success or failure. RESULTS: Data were available for 347 participants. Most (51%) had a criminal record, and 72% achieved housing success. The presence of a criminal background did not predict housing failure. Younger age at move-in, the presence of a substance abuse problem, and higher numbers of drug crimes and property crimes were separately associated with more housing failure; however, when they were adjusted for each of the other variables, only move-in age remained associated with the outcome. CONCLUSIONS: The finding that criminal history does not provide good predictive information about the potential for housing success is important because it contradicts the expectations of housing operators and policy makers. The findings suggest that policies and practices that keep homeless people with criminal records out of housing may be unnecessarily restrictive.