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Official websites use. Share sensitive information only on official, secure websites. Corresponding author. Elsevier hereby grants permission to make all its COVIDrelated research that is available on the COVID resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 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. 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. 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. 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. Drug overdose mortality in the United States has increased over the past decades, with recent surges driven primarily by overdose deaths involving synthetic opioids Wilson et al. People experiencing homelessness PEH are disproportionately impacted by this epidemic: PEH are more likely to misuse opioids Doran et al. Beyond overdose, substance use disorders SUDs like opioid use disorder OUD increase risk for chronic health conditions, including HIV and Hepatitis C infection, and other psychosocial concerns, such as depression, unemployment, and incarceration Haider et al. Homelessness similarly conveys increased risk for physical and mental health morbidities Fazel et al. However, PEH encounter multi-level barriers that commonly impede their obtaining of effective care. Personal barriers such as competing priorities, trauma, and medical comorbidities, practical barriers such as transportation and medication security, and structural barriers such as stigma, mistrust of medical institutions, and lack of health insurance coverage Davies and Wood, collectively contribute to poor access to ambulatory care by PEH and the persistence of unmet health needs Baggett et al. Consequently, PEH may tend to delay seeking care and overutilize acute health care systems Davies and Wood, ; Kushel et al. Due to these biopsychosocial issues and patterns of healthcare utilization, effectively engaging and retaining PEH with OUD in evidence-based treatment is conceivably challenging. However, these medications are commonly prescribed in outpatient settings which often have strict induction and program requirements, can be stigmatized and difficult to locate, and suffer from deficient clinical support Kissin et al. Naltrexone is another approved MOUD option but studies regarding its efficacy are mixed Jarvis et al. Though available as an extended-release injectable XR-NTX that is theoretically easier to adhere to than its oral formulation and daily OAT dosing, a systematic review found that many patients who intend to start on the medication never do and that most discontinue prematurely Jarvis et al. Considering the intersecting barriers that steer PEH away from outpatient medical services in conjunction with the difficulties and limitations inherent to these evidence-based options, there is a demonstrable need to improve acceptability and availability of MOUD among PEH. Several innovative treatment models in the United States, including the recent relaxation of methadone rules with take-home dosing during the COVID pandemic Figgatt et al. Existing literature suggests some of these initiatives have been specifically tailored for PEH. We conducted a scoping review of the literature reporting on OUD treatment-associated findings unique to PEH and literature assessing treatment programs designed for PEH. The search was designed to retrieve studies including any treatment modality by combining terms for OUD with terms for housing status Supplementary Material Appendix A. We searched on April 17, without date or language restrictions. Controlled vocabulary terms were included when available. We used Covidence to manage and organize citations Kellermeyer et al. Two reviewers independently screened titles and abstracts of the records retrieved in the search. Researchers selected records for full-text review if their abstract referenced drug use, unless specifically use of drugs other than opioids, and homelessness or vulnerable housing. Of those selected for full-text analysis, we initially included 1 quantitative and qualitative articles and brief reports that contained findings related to the intersection of opioid use and housing status. However, due to the large number of resulting articles, we narrowed our review to include only the subset of those that reported on 2 the intersection of OUD treatment and housing status. Throughout the record screening process, we excluded all 1 review types, 2 opinion articles lacking primary data, 3 theoretical articles, 4 case reports, 5 abstracts and dissertations, and 6 studies conducted outside of the United States. We also excluded 7 studies published before , when the Drug Abuse Treatment Act of allowed outpatient prescription of buprenorphine, substantially changing the landscape of OUD treatment Wesson and Smith, We developed a standardized template for data extraction. Two reviewers independently extracted data from selected articles, including study details e. We also recorded related details such as varying operationalizations of housing status. Discrepancies in extraction were resolved by consensus after discussion with a third author. We utilized a narrative synthesis approach to organize and present relevant findings. Narrative synthesis is indicated for systematic reviews when a specialized form of synthesis e. This approach is characterized by textual summaries and explanations of findings, which are first synthesized by thematic analysis to allow for the exploration of relationships among studies. Thematic analysis involves iteratively identifying, classifying, and sorting the most important themes and concepts across studies Popay et al. We employed a combined inductive and deductive analytical approach Roberts et al. The preliminary thematic analysis was conducted by MM, which involved open coding of relevant findings from individual studies with short, descriptive phrases e. After coding, 13 unique descriptive themes, stratified by our two deduced categories, were initially generated to classify and capture all relevant findings. With analytical input from RL, NDC, and AC, these themes were iteratively refined and consolidated prior to and during manuscript production. Emergent patterns were synthesized and narratively reported. Our search strategy returned references. After removing exact duplicates, we screened titles and abstracts and excluded citations. We screened full-text citations and included 60 based on our revised inclusion criteria Fig. Forty-three included studies were descriptive and reported on specific ways PEH accessed or engaged with OUD treatment as well unique outcomes they faced compared to populations not experiencing homelessness Table 1. These studies were heterogeneous with respect to setting and reported outcomes. Seventeen described or assessed novel opioid treatment models or interventions tailored to PEH Table 2. Of the sixty included studies, twenty-seven reported on opioid use treatment access and engagement among PEH Amodeo et al. 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. Among homeless-experienced women in Los Angeles, those who preferred heroin, as compared to other substances, accessed substance use treatment programs more frequently Upshur et al. However, in a comparable population, recent engagement with treatment was not associated with motivation to quit heroin Nyamathi et al. Being specifically in MOUD treatment was more likely for veterans experiencing homelessness who were under 35 years old, veterans with fewer opioid and benzodiazepine prescriptions Midboe et al. Still, treatment with buprenorphine or methadone rarely occurred among a cohort of PEH who died from overdose in Boston Bauer et al. PEH accessed inpatient treatment more often than outpatient treatment for the use of opioids and other substances Corsi et al. Masson et al. Two studies similarly found that methadone maintenance therapy MMT and other outpatient treatment services were more likely to be accessed by housed individuals Corsi et al. In contrast, a latent class analysis in Ohio found the prevalence of homelessness to be meaningfully higher in classes characterized by heavy illicit opioid use and the most reported recent SUD treatment i. Krull et al. Relatedly, a significant majority of recovery homes near Nashville were found to bar discharged inpatients from remaining on any MOUD in Patel et al. Moreover, not only were turbulent living conditions described as a significant barrier to recruitment for an XR-NTX clinical trial Hoffman et al. Studies assessing both methadone and other MOUD i. Moreover, the prevalence of homelessness among veterans initiating methadone or buprenorphine treatment was only Despite apparently diminished access to MOUD, in one study, homelessness among inpatients receiving addiction consultation predicted higher rates of initiation of medications for OUD or alcohol use disorder Englander et al. While one study found that out-of-treatment individuals not experiencing homelessness were more likely to have participated specifically in methadone detoxification Royse et al. Though PEH experienced similar Alford et al. While a quantitative and a qualitative study respectively found unstable housing to be related to diminished retention Damian et al. However, two of these studies found nonsignificant negative associations between homelessness and days in treatment Cousins et al. Other heterogeneous MOUD-related findings included greater depressive symptomatology among pregnant women in treatment for OUD experiencing both housing and food instability Rose-Jacobs et al. At least five studies described findings pertaining to opioid detoxification among PEH Kertesz et al. PEH experienced similar if not better detoxification-associated outcomes compared to housed individuals Kertesz et al. A Boston study found that homelessness was associated with a later first use post-detoxification for individuals who preferred heroin Kertesz et al. Additionally, homelessness was not a significant correlate of being uninsured in a sample of individuals seeking opioid detoxification in Massachusetts Stein et al. In terms of detoxification aftercare, PEH were significantly more likely to prefer residential treatment, as compared to OAT or outpatient treatment Stein et al. One study looked at characteristics of treatment admissions for prescription opioid misuse and found that PEH admitted to federally-funded treatment programs were significantly more likely than housed individuals to report higher-risk routes of consumption, including injection and inhalation, rather than oral use Jones et al. Buzza et al. Three studies assessed integration of OAT programs into existing public health infrastructure Hersh et al. For example, Hersh et al. When buprenorphine treatment was integrated into two syringe exchange programs, neither program retention nor transfer to another clinic for maintenance therapy varied significantly by housing status Hood et al. One qualitative study described mixed perspectives regarding video directly observed therapy VDOT , which involves monitored video recordings of daily medication intake, as a potential, innovative model for OAT adherence Godersky et al. While most patients thought VDOT might improve adherence by mitigating logistical barriers and enhancing access to providers, others questioned its practicality due to the unique technological barriers experienced by PEH and other marginalized populations. Four intervention-focused articles reported on or evaluated shelter-based opioid therapy Chatterjee et al. Specifically, Chatterjee et al. In a qualitative study within the same setting, PEH who were part of families described shelter-based buprenorphine treatment as convenient and able to offset common barriers to treatment, including transportation, child care needs, and strict clinic requirements Chatterjee et al. Another shelter-based program in California offering buprenorphine implemented shared medical appointments which were attended by medical, behavioral, and social specialists Doorley et al. A few studies conducted in New York assessed the efficacy of the Housing First approach Tsemberis et al. One study found significantly higher MMT retention for individuals with severe mental illness placed in supportive housing compared to a group of PEH receiving MMT without housing Appel et al. Moreover, this study and one other reported higher rates of housing retention Appel et al. Consistent with these outcomes, one study also found individuals were less likely to use opiates or stimulants at follow-up when they participated in supportive housing programs encouraging harm reduction rather than abstinence Davidson et al. We found two studies evaluating the efficacy of novel nurse-led interventions aimed at decreasing substance use among youth experiencing homelessness and gay and bisexual PEH Nyamathi et al. The former study compared substance use outcomes between participants randomized to a nurse-led health promotion program and those randomized to develop creative messages pertaining to substance use and health for other youth Nyamathi et al. Neither experienced significant reductions in heroin use at follow-up. Consistent with previous findings of high rates of emergency department utilization and hospitalizations among PEH Kushel et al. Given buprenorphine and methadone are more effective at reducing overdose risk and opioid-related morbidity than naltrexone maintenance therapy, inpatient, residential, or behavioral services Wakeman et al. However, despite consistent evidence of decreased access to OAT, studies did not clearly demonstrate that homelessness was associated with worse treatment efficacy once PEH became engaged. While studies found diminished retention Damian et al. Additionally, Riggins et al. Because PEH may equivalently benefit once enrolled, there remains a need to explore and mitigate barriers, including structural ones, that contribute to their suboptimal rates of induction into agonist therapy. In addition, while buprenorphine and methadone are comparably effective at treating OUD, addressing PEH-related limitations unique to each treatment modality is urgently needed to offset this disparity in accessibility. For example, a buprenorphine prescription requires a secure storage space and may not be permitted in some shelters or recovery residences Patel et al. Extended-release i. Though PEH largely underutilize OUD treatment, especially pharmacotherapy, innovative treatment models that aim to address these limitations and disparities have been established and reported in this review. PEH experience logistical barriers and competing priorities impeding appointment and medication adherence in standard, office-based MOUD programs. Models that lower access thresholds and remove obstacles to treatment, such as mobile and street-outreach MOUD clinics Buzza et al. These low-barrier, accessible options are extremely important now more than ever, as the COVID pandemic has substantially disrupted the availability of in-person medical appointments and OUD treatment. In fact, though not necessarily tailored to PEH, regulatory changes during the pandemic have allowed for take-home methadone dosing Figgatt et al. Unlike these successful MOUD models, educational and behavioral interventions were largely ineffective at improving opioid use outcomes for PEH. However, they were successful at achieving their intended outcomes of generally reducing substance use among this population Nyamathi et al. This task-sharing of evidence-based care may aid in addressing existing gaps in OUD treatment provision Magidson et al. We also found that PEH who use opioids benefitted from supportive housing initiatives that were not contingent on substance use treatment or sobriety Appel et al. PEH in these supportive housing programs experienced greater MMT retention compared to unhoused counterparts Appel et al. Consistent with research finding harm reduction approaches to be more successful at retaining and treating individuals with SUDs Padgett et al. It is important to note that these three studies were conducted in progressive urban contexts and that abstinence from substances, including substances like opioid agonists that treat addiction, is still a prerequisite for many residential treatment and housing programs Patel et al. Moreover, even with policy priorities shifting towards more permanent housing options for PEH, homeless service systems in the United States were only able to offer year-round beds to slightly more than half of individual PEH in National Alliance to End Homelessness, This housing shortage, in addition to the persistence of abstinence-only housing programs, poses a significant threat to the management of OUD and other SUDs among homeless populations in the United States. Some of the interventions identified in this review have likely demonstrated success because they adhere to well-developed frameworks such as the healthcare for the homeless HCH model Zlotnick et al. HCH interventions are characterized by outreach and engagement, community collaborations, case management, and respite care. Among our included studies, we found strong concordance with these first three features. Successful opioid treatment programs for PEH are flexible, dynamic, and on-demand, implementing measures which move the point of care out of the clinic in order to meet patients where they are at Carter et al. These efforts respond to documented transportation and access barriers experienced by PEH Chatterjee et al. Moreover, many of these programs tolerated continued missed appointments and gaps in care, which are expected among patients with housing instability and multiple morbidities, as well as relapse and polysubstance use Carter et al. Efficacious interventions involved collaborations with community clinics, pharmacies Buzza et al. While we did not find opioid use treatment literature involving respite care, transitional shelter-based and supportive housing programs successfully supported these populations in addressing their opioid use Appel et al. Although innovative programs have been developed to address the unique challenges that PEH who use opioids experience, our review reveals there is still limited information with which to evaluate them. Included outreach and street medicine studies were in early stages of evaluation. Studies of shelter-based programs were scarce and limited by small sample sizes and lack of comparison groups. Moreover, while Housing First interventions for PEH with SUDs have been shown to be effective under certain conditions, their heterogeneous implementations limit uniform success Davidson et al. Ultimately, more work is needed to rigorously evaluate and progress these interventions in the field. Considering that the results from a pilot study evaluating a mobile buprenorphine treatment program for veterans were published shortly after our search date Iheanacho et al. We additionally noticed deficits in how the literature assesses OUD treatment and race in relation to homelessness. While both effectively treat OUD Wakeman et al. Interestingly, one of our included studies found that a mobile OAT treatment program more successfully recruited Black individuals as well as PEH than a fixed-site methadone clinic Hall et al. It follows that OUD treatment programs tailored to reach PEH may benefit other populations, including racial and ethnic minorities. Because people of minority racial identities may suboptimally interact with OUD treatment options related to a legacy of racism in health care and addiction treatment, such programs must work to ameliorate experiences of trauma and sentiments of mistrust among these populations. Offering the option to forgo toxicology screening due to prior traumatic experiences with urine testing Carter et al. Immigration status is also an issue that overlaps with homelessness and shapes access to OUD treatment, via insurance coverage, but is not explored in the existing literature. There are several limitations to our review. We only included studies that assessed the relationship between homelessness and treatment for opioid use. Though several studies examined populations with non-trivial prevalences of homelessness, they were not included if they did not report on the distinct connection between housing or housing status and treatment outcomes or models. As a result, certain studies evaluating novel treatment interventions for opioid use were excluded, even though some may have been beneficial for PEH. Conversely, some of our included findings did not necessarily tease out independent relationships between housing status and treatment specifically for opioid use. For example, Davidson et al. However, considering the pervasiveness of polysubstance use Crummy et al. Our synthesis was also limited by variable times and locations of data collection. Outcomes related to OUD treatment may vary by regional and generational differences in substance use trends and epidemiological factors. For example, the primary opioid associated with overdose in the United States has changed over time, with a marked transition from heroin to fentanyl occurring within the last decade Hedegaard et al. These differing contexts limit generalizability, particularly of findings pertaining to treatment outcomes, and may hinder direct comparison of study results. Finally, definitions of homelessness and housing statuses varied widely by study, and analyses sometimes included subcategories of vulnerable housing. Merely synthesizing this data oversimplifies the differing contexts of specific living conditions and the assumptions underlying study findings. Researchers, policymakers, and healthcare professionals must discover and evaluate ways to respond to the needs of specific communities, with the guidance of existing recommendations for healthcare for PEH. This scoping review surveyed the current body of literature assessing how PEH access and experience OUD treatment, identifying sustained barriers and recognizing preliminarily efficacious, flexible treatment strategies situated within the HCH model. Expanding upon the findings from these recent developments will be crucial to mitigate the hugely disparate burden of opioid-related morbidity and mortality experienced by PEH in the United States. McLaughlin, R. Li, and N. Li, N. Chatterjee analyzed the data. Bain developed the search strategy. All authors contributed to the writing of the manuscript and development and conceptualization of the scoping review. We acknowledge the patients and staff at the Boston Healthcare for the Homeless Program. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Drug Alcohol Depend. Find articles by Matthew F McLaughlin. Find articles by Rick Li. Find articles by Paul A Bain. Concord St. Find articles by Avik Chatterjee. All rights reserved. Open in a new tab. Over the month period, no significant associations were found between housing status and use of opioids or other drugs. Amodeo et al. Bachhuber et al. Male vs. Bauer et al. In particular, treatment with buprenorphine 4. Chang San Francisco, CA Qualitative study Formerly homeless women living in supportive housing Participants described being tethered to the Tenderloin because they needed to access substances or treatment, including substitution therapy. One participant was on methadone maintenance treatment for OUD and felt geographically tied to the neighborhood due to requirements that she obtain methadone treatment on-site at the clinic daily. Corsi et al. Cousins et al. Damian et al. Daniulaityte et al. The 'More Formal Treatment Use' class had a Dunn et al. Englander et al. Eyrich-Garg et al. Fine et al. Havens et al. Hoffman et al. Turbulent living conditions were considered to be a universal barrier to recruitment. One clinician explained that in her clinic, recruiters 'might have hooked in with somebody but then the housing falls through and then we lose them. Kelly et al. Kertesz et al. Krawczyk et al. Li et al. Lundgren et al. Midboe et al. Nyamathi et al. Patel et al. Reynoso-Vallejo et al. Rivers et al. Riggins et al. Robbins et al. Rose-Jacobs et al. Royse et al. Shah et al. Simon et al. Stein et al. There was no evidence that the relationship between homelessness and treatment preference varied by season. Timko et al. Upshur et al. Van Ness et al. Velasquez et al. Clinicians regularly visited homeless encampments and maintained availability during follow up. The authors are in the process of formally evaluating the program's preliminary reach and efficacy. Carter et al. Chatterjee et al. Barriers to care included logistical ones such as transportation, child care needs, and discharge from clinics as well as stigma and triggers. Ideal treatment was described as helping pain management and comorbidities and involving overdose prevention and the convenience of shelter-based treatment. No overdoses were documented during the study period. Initial urine drug tests indicated that two had used opioids, and one patient had an opioid-positive urine drug test by the third month. In the final month of treatment, 3 patients were employed as compared to 1 at treatment initiation. Of the 4 who moved from the shelter system to an office-based program, all relapsed and lost custody of their children. Davidson et al. There were no significant differences in stimulant or opiate use between baseline and follow up among clients of programs with high supportive housing fidelity. Doorley et al. The median and mean attendance were 10 and 18 shared appointments, respectively. Godersky et al. Video directly observed therapy was described as a potential solution by mitigating logistical barriers and enhancing access to providers. Hall et al. Hersh et al. Hood et al. Neither retention in Bupe Pathways nor transfer to another clinic for ongoing buprenorphine maintenance varied significantly by housing status. Housing status was not significantly associated with remaining in care after 30 days. While treatment extended beyond 90 days for some clients, the majority did not require extended treatment. However, baseline opiate use in both groups was low. Tringale et al. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Alford et al. The number of patients who left treatment and the reasons for leaving treatment before 12 months, including the treatment failure and successful program departure groups, appeared similar for both homeless and housed patients. Female individuals who inject drugs and reported heroin as primary drug. The prevalence of homelessness was Fewer than half of decedents with documented opioid use had received pharmacological treatment for opioid dependence. Chang San Francisco, CA. Participants described being tethered to the Tenderloin because they needed to access substances or treatment, including substitution therapy. Not considering oneself to be homeless was significantly associated with treatment entry i. Past 6-month homelessness significantly differed between classes. Homeless individuals vs. Patients initiating detoxification and outpatient OUD treatment. Homelessness impeded prospective participants' ability to engage in the study. Jones et al. Marienfeld and Rosenheck USA. Patients who used medical services and had a diagnosis associated with complications of opioid use. Veterans who accessed homeless programs in the Veterans Health Administration. Recent substance use treatment was not significantly associated with a motivation to quit for people who used heroin. Of the recovery houses that accepted discharged patients from Vanderbilt Medical Center in , Patients seeking treatment at an office-based opioid treatment program. Patients who preferred residential treatment after detoxification were more likely to be homeless than those who preferred OAT or those who preferred outpatient treatment. Homelessness was not significantly correlated with being uninsured. Veterans Health Administration patients with alcohol or opiate dependence. Homelessness was not significantly associated with odds of using a methadone clinic. Recent or chronic homelessness was described as a primary barrier to adhering to prescribed treatment i. Appel et al. Methadone treatment retention for 31 patients placed in supportive housing vs. The mean treatment duration was 7. Individuals experiencing homelessness who misused substances. Patients referred for a buprenorphine shared medical appointment in a homeless shelter clinic. Homelessness was identified as a major barrier to buprenorphine adherence, both in the context of keeping appointments in order to have prescriptions filled and also taking medications regularly as instructed. Patients enrolled in low-barrier buprenorphine treatment i. Patients with OUD who were recently incarcerated or exiting jail. The majority Lashley Baltimore, MD. Reductions in heroin use at 6-month follow up in both the health promotion and art messaging groups were not significant.

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Al Rayyan buying Heroin

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Al Rayyan buying Heroin