Prevention of OUD: The HOME (Housing, Opportunities, Motivation and Engagement) Feasibility Study

Young adults experiencing homelessness are at high risk of opioid and other substance use, poor mental health outcomes, exposure to trauma, and other risks. Providing access to stable housing has the potential to act as a powerful preventive intervention, but supportive housing programs have been studied most often among chronically homeless adults or adults with serious mental illness. The Housing First model, which does not precondition supportive housing on sobriety, has been shown to reduce drug use in homeless adults. In the present study, we piloted an adapted model of Housing First that was tailored to the needs of young adults (18–24 years) experiencing homelessness. Supportive services were added to the Housing First model and included youth-centered advocacy services, motivational interviewing, and HIV risk prevention services. This model was piloted in a single-arm study (n = 21) to assess the feasibility, acceptability, and initial ecacy of a Housing First model over a 6-month period. We use repeated measures ANOVA to test for changes in alcohol and drug use (percent days of use; alcohol or drug use consequences), housing stability, social network support, and cognitive distortions over 6 months of follow-up. A total of 17 youth completed the study (85% retention) and a high proportion of youth were stably housed at 6-month follow-up. Participation in intervention services was high with an average of 13.57 sessions for advocacy, 1.33 for MI, and 0.76 for HIV prevention. Alcohol use did not change signicantly over time. However, drug use, drug use consequences, and cognitive distortions, and the size of youths’ social networks that were drug using individuals decreased signicantly. The Housing First model appeared to be feasible to deliver and youth engaged in the supportive intervention services. The study demonstrates the potential for an adapted Housing First model to be delivered to youth experiencing homelessness and may improve outcomes.


Introduction
Housing First is a model of supportive housing that provides persons experiencing homelessness with immediate access to shelter in independent living without prerequisites. Traditional housing services often require graduated access to shelter upon attainment of sobriety or acceptance of a particular volume of services. In contrast, Housing First asserts that shelter is a right and should not be contingent upon sobriety or speci c services.
Originally developed by Pathways to Housing 1,2 , Housing First models to date target elderly with signi cant disabilities, adults with severe mental disorders and Medicare patients with high-cost medical conditions. In general, Housing First has been effective at increasing the number of days housed for these populations, reducing costs for medical and jail services, and increasing the receipt of traditional services 3,4 . It is less clear whether Housing First reduces substance use or improves mental health conditions over time. Moreover, it has not been evaluated among youth or with regards to prevention of substance use disorder. Gaetz 5 argues that youth are an ideal population for a modi ed version of Housing First. Intervening early would allow prevention services to be delivered and to house youth before they become part of the chronically homeless population. He also recommends modifying the Housing First model to include youth-focused case management or advocacy and diverse housing options given the many ways youth become homeless. Because of its success with adults with a variety of conditions, Housing First has been implemented with a youth focus in Northern Europe, California and several cities in the eastern and midwestern US 6 , but there are no data published on the characteristics of youth included in the model, the services they received, or the initial experience.
In response, our team conducted a study 7 in which we delivered an adaptation of Housing First focused on a subsample of youth experiencing homelessness-women with young children. Speci cally, women with young children (N = 60) were randomly assigned to either a Housing First-type model (n = 30) or treatment as usual (TAU) through a shelter (n = 30). Location and type of housing was of the women's choosing and included three months of utility and rental assistance plus an advocacy program, Strength Based Outreach and Advocacy (SBOA). The housing intervention yielded decreased drug use (Cohen's d = 0.61) and more independent living days (Cohen's d = 0.63) over usual shelter services. Two-thirds of women in the housing intervention were successful in maintaining their apartments six months after rental assistance ended.
In the present study, we build on this prior work by expanding the sample to include a more diverse group of youth experiencing homelessness and to add a longer period of rental and utilities support (up to 6 months). In addition, we further adapted the model with additional preventive services in order to explore the potential of Housing First for prevention of opioid use disorder (OUD) and related risks. To that end, the Housing First model was combined with SBOA, as well as other risk prevention services including motivational interviewing and HIV prevention. We present the results among the study's sample of 21 youth from a large Midwestern city and discuss our ndings as proof of concept for public housing authorities and grant funders.

Methods
This was a single-arm longitudinal feasibility study of a modi ed Housing First model for youth. Youth were recruited from the drop-in center for homeless youth in Columbus, OH. We included youth between the ages of 18 to 24 years who met the criteria for homelessness as de ned by the federal McKinney-Vento Act (2002) as "lacking a xed, regular, stable, and adequate nighttime residence" and includes "living in a publicly or privately operated shelter designed to provide temporary living accommodations, or a public or private place not designed for, or ordinarily used as, regular sleeping accommodations for human beings" and b) did not have existing Opioid Use Disorder. The Structured Clinical Interview for DSM-5 Disorders (SCID) is a semi-structured diagnostic interview that is used to make DSM-5 diagnoses 8 for baseline eligibility. After the brief screening and stated interest in the project, written consent was obtained. A total of 21 youth were enrolled in the study.

Intervention: Modi ed Housing First for Youth with SBOA
All youth in our study received six months of rent and utilities plus SBOA and preventive interventions focused on HIV and opioids.
SBOA. SBOA focused on identifying and engaging youth from the streets and drop-ins/shelters etc. and assisting these youth to meet their basic needs (i.e., referrals to food pantries), obtain government entitlements (i.e., SSDI/SSI, cash assistance, food stamps), and connect to other needed supports (education, job training). The advocates provided referrals and/or transport youth to appointments as needed. Advocates were available 24 hours for crises.
Housing. The advocate worked with the youth to identify appropriate scattered site housing among the available choices and initiated the procedure for payment directly to the landlord once housing was identi ed. The project covered damage deposit, application fees (including FABCO report, credit report), and automatic rent payments to the landlords and utility companies at the beginning of each month.
HIV prevention. Every youth was scheduled for a 2-session intervention which uses cognitive-behavioral techniques with a focus on skills building/behaviors (role plays with condom application, cleaning

Assessment
The baseline and follow-up assessment included self-report obtained from surveys and structured interviews. An interviewer-administered demographic/homeless experiences questionnaire assessing a set of core variables (including childhood abuse, intimate partner violence and street victimization experiences). The primary measure of substance use quantity and frequency was assessed through the

Analysis
Repeated-measures ANOVA was used to test the e cacy of the intervention (time effects). Three testing occasions (e.g., baseline, 3, and 6 months) were used as the within-subject dependent variables. The alpha level was adjusted using the Bonferroni correction. It was predicted that there would be a main effect of time; youth were expected to show reductions in opioid use, and improved functioning in other domains at six months after baseline.

Results
Attrition was the main reason for missing data in the current project. The number of participants who completed the baseline, 3-, and 6-month assessment was 21, 19, and 17, respectively. Missing data patterns were examined using Little's MCAR test, which was not signi cant [χ 2 (1152) = 10.94, p > 0.05] suggesting random missingness.

Sample characteristics
Demographic characteristics are listed in Table 1. More than half of the sample (n = 15, 71.4%) held a job in the past 12 months. Seven youth (33.3%) reported having been arrested at least once as a juvenile, and 12 youth (57.1%) were arrested at least once as an adult (Table 2). More than half of the sample (n = 13, 61.9%) had received a psychiatric diagnosis from a mental health professional. Six youth (28.6%) reported suicide attempts during their lifetime. The average number of lifetime suicide attempts was 2.60, ranging from 1 to 5. The percentage of youth that reported a history of sexual, physical, and verbal abuse was 42.9% (n = 9), 52.4% (n = 11), and 57.1% (n = 12), respectively. During the past 12 months, youth stayed 2.86 nights on average in their own, stable housing and their most frequently reported places of shelter were the drop-in center, followed by homeless camp.

Substance Use
None of the youth consumed opioids during the six months of the project (Table 3)

Housing
On average, in the percentage of days housed signi cantly increased over time (F [2,30] = 77.18; p < 0.01) from 8.06% (SD = 24.23) at baseline to 92.88% (SD = 18.03) at 6-m follow-up. The increase was clearly due to the housing provided by the study.

Social Network
On average, over six months of the treatment, participants reported no changes in the family network size, but non-family network size reduced signi cantly (F [2,30] = 5.39; p = .01, Table 3.) from baseline (M Non−fam = 0.64, SD = 0.16) to 6-m follow-up (M Non−fam = 0.47, SD = 0.27). Moreover, the frequency of support from drug using individuals was signi cantly reduced (F [2,30] = 11.70; p < .001.) These changes might be due to supports that youth received from the advocates and a change in network characteristics as a result of housing stability.

Discussion
Our experience with this pilot study of a youth-adapted Housing First model extends our previous study on Housing First for young mothers experiencing homelessness to a broader group and provides more detail on youth experiencing homelessness in our community. The 21 largely minority youth represented a very high-risk group with marked rates of drug use and suicidal behavior along with few prospects for housing. By providing housing, utilities, SBOA and other preventive services, our sample was highly engaged in the support services, remained almost completely housed, and showed improvements in cognitive functioning and drug-related consequences in the short term. Total drug use trended lower. Several limitations should be considered. This study was a small nonrandomized pilot study, testing initial e cacy, feasibility of recruitment and engagement in the housing and opioid prevention services. The youth were approached in a drop-in center in a large urban Midwestern city, representing a convenience sample. The ndings might not generalize to youth in other parts of the country who do not access a drop-in center or shelter. However, we engaged a sample of Black and African American or mixed youth, nearly equal proportion of females (48%) to males, and a high proportion of sexual and gender minority youth (47%), consistent with previous samples.
In addition to testing for signals of initial e cacy of the prevention intervention on opioid use and secondary outcomes, this pilot study sought to test the feasibility of engaging and retaining youth experiencing homelessness in the intervention and housing. An important question was whether it would be possible to identify housing for youth and engage landlords to rent apartments to youth. This is a challenge given high rental costs, and because our youth often have prior criminal records, prior evictions, and poor credit history. However, we recruited our entire sample in three months and successfully found housing for all youth. Even using remote contact strategies like video, texting and telephone as COVID precautions, youth were very engaged. The study was reviewed and approved by the Ohio State University Institutional Review Board. The study obtained written informed consent from all research participants.

Consent for Publication
Not applicable.

Availability of Data and Materials
Data from the study will be released to the pubic after appropriate de-identi cation through the NIH HEAL Prevention Collaborative, coordinated by RTI, no later than one year after three-year outcome data are collected.
Competing Interests are appropriately investigated, resolved, and the resolution documented in the literature. No professional writers were used.

Figure 1
The HOME Project Phase I Consort