Since 2002, the United States federal government has articulated a commitment to ending chronic homelessness, offering targeted funding, logistical support, and aggressively promoting community planning at the state and local levels.1-5
As of August, 2006, 222 communities had announced 10-year planning processes dedicated toward this goal (Personal Communication, Mary Ellen Hombs, United States Interagency Council on Homelessness, August 3, 2006). An estimated 1.4-2.1 million adults experience homelessness each year in the United States.6
Although homelessness reflects a complex array of structural and personal vulnerabilities,6, 7
substance abuse and dependence are contributing factors.8, 9
In many communities, residential addiction treatment programs are the major point of entry to the network of available services. In light of the rejuvenated national focus on ending chronic homelessness4, 5, 10
it is important to document how, and whether, addiction treatment can contribute to improvements in long-term housing and employment, especially because treatment services are heavily used. In national survey data, among homeless persons with a drug abuse history (58% of the total), 17% reported receipt of inpatient or residential treatment within the past year (most reporting 2 or more episodes), potentially reflecting up to ½ million inpatient treatment episodes per year among homeless persons.11
In most communities, homeless addiction treatment is intensive, time-limited (1-6 months), and fortified with referrals to a range of services that in principle should be “seamless” with the treatment itself.12
Successful clients may return to work and housing or advance to transitional residential programs as part of a local “continuum of care” that can include private recovery homes, federally funded transitional housing, or long-term supportive housing with federal or local support. An objective assessment of the rehabilitative outcomes obtained from addiction treatment programs could be helpful to the communities now planning to end chronic homelessness.2
However, the success of these programs in facilitating long-term housing and employment among homeless substance-abusing persons remains unclear, for at least 3 reasons:
First, some observational studies that profile housing after addiction treatment lack specific data on the particular treatments offered.13
Second, a number of prospective addiction treatment trials among homeless individuals failed to show that one trial arm was more effective than another.14-16
While such findings may be compatible with treatment benefit insofar as improvements are noted among all participants who attended (regardless of trial arm), the lack of differences by trial arm limits the strength of causal attributions.
Third, published treatment outcome findings may be suboptimum from a policy perspective when intervention effects are analyzed in terms of continuous outcomes such as “number of days housed.”17, 18
A report that case management or short-term housing interventions produced, on average, 4-6 additional days of housing can be difficult to translate to policymakers who are required by funders to track the absolute number of persons housed successfully.
Therefore, this project sought to characterize the proportion of homeless, psychiatrically distressed cocaine-dependent clients for whom a 6-month evidence-based, behaviorally-oriented addiction treatment (in which 2 out of 3 trial arms experienced significantly superior abstinence outcomes, as previously reported19
) was followed by stable housing and employment at 12 months. All participants were offered behavioral day treatment services, and randomly assigned to receive either no program-provided housing during treatment (No Housing), program-provided housing contingent upon abstinence (Abstinence-Contingent Housing), or program-provided housing not contingent upon abstinence (Nonabstinence-Contingent Housing).20
Elements of the 6-month treatment service package (including psychoeducational groups, work therapy, therapeutic goal management and, in 2 trial arms, housing) had efficacy in reducing substance use in a series of randomized controlled trials.20-22
Published trial results showed superior week-to-week abstinence during treatment for the two housing intervention groups (Abstinence-Contingent Housing & Nonabstinence-Contingent Housing) compared to No Housing, and an advantage for the Abstinence-Contingent Housing group versus Nonabstinence-Contingent Housing over time.20
To provide policy-relevant information, categorical measures for stable housing and employment at one year were developed based on the treatment outcomes data. One research goal was descriptive, i.e. to quantify the proportion of homeless, psychologically distressed cocaine-abusing persons with rehabilitative success 1 year after entering a 6-month treatment. Secondarily, and consistent with the original trial, this study assessed whether 12-month work and housing outcomes were superior among persons who had received the program-provided housing interventions (Abstinence-Contingent Housing & Nonabstinence-Contingent Housing) during treatment.