Drug Use, Homelessness and Health: Responding to The Opioid Overdose Crisis with Housing First Models

3 Background: Canada is in the midst of an opioid overdose crisis and Alberta has one of 4 the highest opioid use rates across the country. Populations made vulnerable through structural 5 inequities who also use opioids, such as those who are unstably housed, are at an increased risk 6 of experiencing harms associated with opioid use. The main purpose of this study was to explore 7 if there was an association between unstable housing and hospital use for people who use 8 opioids . Methods: Analysis utilized self-reported data from the Alberta Health and Drug Use 9 Survey which surveyed 813 Albertans in three cities. Hospital use was modeled using a logistic 10 regression with our primary variable of interest being housing unstable status. Chi square tests 11 were conducted between hospital use and variables associated with demographics, characteristics 12 of drug use, health characteristics, and experiences of receiving services to establish model 13 inclusion. Results: Results revealed a significant association between housing instability and 14 hospital use, with unstably housed individuals twice as likely to become hospital users. 15 Conclusions: Results highlight the importance of concurrently addressing housing instability 16 alongside the provision of harm reduction services such as Housing First programs and 17 supervised consumption sites. These findings have significant implications for policy and 18 policymakers during the opioid overdose epidemic, and provide a foundation for future areas of 19 research. 20


Background
Canada is currently experiencing a national opioid overdose crisis.Since January 2016, there have been over 15,300 apparent opioid-related deaths across Canada with over 19,300 hospitalizations due to opioid-related poisonings (Government of Canada, 2020).Between 2013 and 2018, hospitalizations related to opioid poisonings across Canada increased by 27%, while rates of hospitalization and emergency department visits continue to rise (CIHI, 2018).The Government of Canada has taken important steps to support individuals who use opioids across the country by increasing access to treatment, expanding awareness and prevention of opioidrelated harms, supporting data collection and research, increasing access to harm reduction strategies such as supervised consumption sites, and working to decrease the tainted drug supply (Government of Canada, 2020).
Alberta continues to have some of the highest rates of opioid-related deaths, emergency department visits, and hospitalizations within Canada.In Alberta, 2,667 individuals died from an accidental opioid poisoning since January 1, 2016, with over 140 deaths already reported in the first three months of 2020 (Government of Alberta, 2020a;Government of Alberta, 2020b).
Emergency department visits related to opioids and other drug use increased 41% between January 1, 2016 and the third quarter of 2019, while hospitalizations related to opioids and other drug use increased 19% between January 1, 2016 and the third quarter of 2019 (Government of Alberta, 2020b).In the last quarter of 2019, Alberta reported over 2,470 emergency and urgent care visits associated with opioids and other drug use, with 13% of individuals visiting more than once (Government of Alberta, 2020b).Although opioid-related deaths, emergency department visits, and hospitalizations are reported at a broad level, there is a lack of publicly available demographic data.Specifically, there is no government-based reporting on opioid use or overdoses specific to individuals who are unstably housed.
According to the National Health Care for the Homeless Council (NHCHC), housing is a crucial social determinant of health and a lack of housing, or being unstably housed, is associated with mental health concerns, physical health problems, trauma, greater mortality rates, and substance use disorders (NHCHC, 2017).Individuals who are unstably housed are at an increased risk of experiencing opioid use and overdose.For example, Yamamoto et al. (2019) found a significantly higher risk of opioid overdose in those who were homeless than those who were housed.Similarly, a study by Doran et al. (2018) revealed a significant association between homelessness and opioid overdose.Results from other studies suggest overdose is the leading cause of mortality in the homeless population with rates up to 17 times higher than the general population (Baggett et al., 2013;Baggett et al., 2015).In British Columbia, a 2017 report revealed almost 30% of individuals who experienced an overdose reported unstable housing, and those with no fixed address were at a higher risk of experiencing repeated overdoses (BC Center for Disease Control, 2017).Finally, Zivanovic et al. (2015) found that unstable housing was independently associated with increased mortality rates, suggesting housing status is an important risk factor to be considered among individuals that use drugs.Thus, there is evidence to suggest there is an association between unstable housing and opioid-related harms.
Individuals who are unstably housed and use opioids often lack access to safe, adequate healthcare and are overrepresented in mental health concerns including substance use, anxiety, and depression (Magwood et al., 2020;Amari et al., 2011;Latimer et al., 2017).Results from some studies suggest housing instability is associated with higher unmet needs and lower rates of access to a family doctor, resulting in significantly more hospitalizations and visits to emergency departments (Khandor et al., 2011;Jaworsky et al., 2016;Hwang et al., 2013).Not only does housing instability and a lack of healthcare impact the individual experiencing inequities, the economic impacts are substantial.In 2013, homelessness was estimated to cost the Canadian economy more than $7 billion annually including costs associated with healthcare services (Gaetz et al., 2013).Furthermore, Latimer et al. (2017) examined the costs associated with housing homeless individuals with mental health concerns across five Canadian cities and found the average annual cost ranged between approximately $29,000 and $56,000 per person.These authors argue that for every $1 invested in housing and individualized case managed supports, resulted in an average savings of just over $2 in public costs.
To build upon the knowledge surrounding the importance of housing as a critical social determinant of health within the opioid epidemic, the purpose of this study was to examine if housing instability was associated with an increased likelihood of accessing hospital services for problems with emotions, mental health, or alcohol/ drug use with additional variables of interest including demographics, drug use characteristics, health characteristics, and/or experiences receiving services.

Participants
We utilized self-reported data from the Alberta Health and Drug Use Survey results (Alberta Health and Drug Use Survey, 2017 which surveyed 813 Albertans in three cities, Calgary, Red Deer and Medicine Hat.Participants were recruited through local coalitions of service providers in those cities.Information was collected on: 1) socio-demographics, drug use and health; 2) drug use, risk behaviours, and experience of harm; 3) outcomes related to health status, health service use, and unmet healthcare needs; and 4) acceptability of potential new health services.For the purposes of the current study, the total analytic sample was 432 participants and included those participants who: 1) reported using opioids via injection or noninjection within the six-month period prior to participating in the Alberta Health and Drug Use Survey (carfentanil, china white, codeine, demerol, fentanyl, heroin, hydrocodone, hydromorphone, methadone, morphine, oxycodone, oxycontin, oxyneo, percocet, speed 1 Procedure Data was analyzed using Stata.Hospital use was modeled using a logistic regression with our primary variable of interest being housing unstable status.Chi-squared tests were conducted between hospital use and potential confounders..All demographic variables were included in our final model.Variables regarding characteristics of drug use, health characteristics, and experiences receiving services were included if they met a relaxed significance value (p ≤ 0.1) and had variance inflation factors (VIF) scores below 2.5 when tested for multicollinearity between independent variables (in a logistic regression on hospital use, not reported).Testing for multicollinearity was conducted due to the multiple variables measuring drug use characteristics.
Variables with the highest p-values were removed from the model until the coefficients from the initial model showed a change larger than 20%, which constituted our threshold for confounding.
At this point, all variables were left in the model and were considered confounders.
Once the final set of variables was established, interaction effects were tested for between demographics and other explanatory variables, only keeping the significant interactions.
The adjusted model contained a single significant interaction effect: sex and diagnosis with addiction or a mental health disorder.

Sample Characteristics by Hospital Use with Pearson Chi-Squared Results
Table 2 presents sample characteristics by hospital use and results from the chi-squared tests assessing the association between hospital use and demographics, characteristics of drug use, health characteristics, and experiences receiving services.
Of the 432 participants, the majority were unstably housed (55.6%), male (65.3%), non-Indigenous (67.4%), and had an average age of 37.4 years (range between 16 -68).Regarding hospital use, 42.4% of participants reported using hospital care (overnight or longer) within the six months prior to being surveyed.Among those that reported using hospital care, 67.8% of participants indicated unstable housing compared to those that did not use the hospital where only 46.6% indicated unstable housing.When looking at location and hospital use, hospital users were more likely to be in Medicine Hat or Red Deer (53.6%).
Of the 432 participants, 31.7% had reported an overdose within the six months prior to taking part in the survey, 53.9% of participants reported using drugs 2-3x per week or more, and 77.1% reported being heavily influenced by drugs weekly or daily.Chi-squared test results revealed multiple significant associations between participants who reported hospital use and characteristics of drug use such as overdosing (p = <0.001),frequently neglecting other tasks due to use (p = <0.001),frequently needing to use in mornings after heavy usage the night before (p = 0.004), frequent polydrug use (p = 0.003), frequently being heavily influenced by drugs (p = 0.011), others noting they are worried about the participants use (p = 0.004), frequently feeling an irresistible longing to use (p = 0.038), frequently feeling guilty due to drug use (p = 0.023), and believing that themselves or others have been hurt due to their use (p = 0.040).In contrast, participants without these higher risk drug use characteristics were proportionally less likely to report hospital use.
Of the 432 participants, 81.2% of participants reported being diagnosed with an addiction or mental health disorder.Chi-squared test results revealed a significant association between diagnosis with addiction or mental health concern and higher likelihood of hospital use (p = 0.001).
Of the 432 participants, 55.1% of participants reported they were unable to access a type of service they felt they needed.Chi-squared test results revealed a significant association between hospital use and more unmet needs due to not having access to needed services (p = 0.017).56.9% of participants reported they were unable to access enough services they felt they needed.

Insert Table 2. Logistic Regression of Hospital Use
Table 3 reports the results from the logistic regression on unadjusted and adjusted models, including an interaction term accounted for in the adjusted results.In the fully adjusted model, participants who reported unstable housing (OR:2.04,95% CI:1.29-3.21),an overdose (OR:3.59,95% CI:2.21-5.83),and neglecting tasks due to drug use on a frequent basis (weekly or more) (OR:2.19,95% CI:1.28-3.73)remained independently significant with a positive association.After testing for interaction effects between variables, the primary variable of interest for unstable housing did not have any significant interactions with the other variables contained in the model.Therefore, while controlling for all other variables in the model, those who were unstably housed were twice as likely to become hospital users.
The interaction effect between sex and having been diagnosed by a professional with an addiction and/or a mental health concern was significant.Among males, the effect of diagnosed status is insignificant and has minimal impact on hospital use; however, among females, those who had a diagnosis of an addiction and/or mental health concern from a professional were 28 times more likely to use the hospital (OR for females with a diagnosis = exp(interaction)*exp(diagnosis)=(22.443)*(1.261)=28.26)than their counterparts.These results indicate that while controlling for all other factors within the model, the effect of diagnosis for addiction and/or mental health concerns among males is minimal or negligible in relation to hospital utilization.In contrast to this, diagnosed status among females has a significant and notable reaction on hospital use.

Discussion
The main purpose of this study was to examine if housing instability was associated with an increased likelihood to access hospital services for problems with emotions, mental health, or alcohol/ drug use specifically amongst individuals who use opioids.Additional variables of interest included demographics, drug use characteristics, health characteristics, and/or experiences receiving services.
Results revealed that being unstably housed was associated with hospital use even after accounting for the additional variables.This finding is similar to previous studies that have found an association between unstable housing and increased utilization of hospital services (Magwood et al., 2020;Khandor et al., 2011;Jaworsky et al., 2016;Hwang et al., 2013).
Housing is considered a crucial social determinant of health and a lack of housing can have serious consequences on the health of homeless individuals.Homelessness has been associated with high mortality rates, extreme poverty, poor oral and dental health, and chronic conditions such as diabetes, seizures, respiratory problems, tuberculosis (TB), Human Immunodeficiency Virus (HIV), and widespread issues with alcohol and drugs (Hwang, 2001).Our findings support the growing evidence base highlighting the importance of housing and recovery-oriented models such as Housing First (Gaetz et al. 2013b).Housing First models are rooted in the belief that housing, not compliance or sobriety, is the foundation for recovery and once housing has been secured, a person can successfully address other areas in their life such as physical health, mental health, substance use, employment, and education (Gaetz et al. 2013b).Housing First models are based on five principles that: 1) allow individuals to access permanent housing with no requirements or conditions; 2) emphasize individual choice and self-determination; 3) focus on recovery within a harm reduction approach; 4) recognize the uniqueness of each individual and their needs once housing is secured; and 5) support individuals to integrate into their community with social supports (Gaetz et al. 2013b).Not only does securing housing increase the physical health and wellness of the unstably housed individual, studies show Housing First reduces hospitalizations and emergency department visits, thereby decreasing the economic costs associated with homelessness (Gaetz et al. 2013b).
As Magwood et al. (2020) purport, homeless individuals with substance use issues benefit from harm reduction strategies, including Housing First, by improving access to care, reducing opioid overdoses, and preventing or limiting the spread of infectious disease and other chronic conditions.Housing First is particularly important for individuals who are using opioids as they are high risk for overdose.Results from a study of people who use opioids who accessed a Housing First program showed a 93% housing retention rate and 100% of participants accessed overdose prevention education and naloxone while in the program (Katzenstein et al, 2019).
Future studies could explore the difference in hospitalizations and emergency department visits for individuals who use opioids and are unstably housed and those in Housing First programs to determine if there is a significant difference between the two groups.
Although the Government of Canada has advocated and approved of harm reduction strategies and over 40 supervised consumption sites nationwide, the current Government of Alberta has halted funding for new supervised consumption sites as of summer 2019, citing socio-economic concerns.Supervised consumption sites provide a monitored environment for individuals who use substances and offer support services such as counselling, social work, and other opioid-dependency treatment options while reducing the transmission of infections and diseases and lowering the risk of overdose (AHS, 2016).The Calgary supervised consumption site responded to over 1,800 overdoses between October 30, 2017 and May 31, 2020 and received over 151,000 client visits during this time (AHS, 2020).A recent study by Jackson showed that each overdose managed at the Calgary supervised consumption clinic saved approximately $1,600 per overdose or over $2.3 million in total emergency health costs since the site opened.Future studies could examine if moving from a harm reduction approach to an abstinence-based approach has resulted in a change in hospitalization and emergency department visits and subsequent costs.
Interestingly, results revealed a significant interaction between sex and having a mental health and/or addiction diagnosis with regard to hospital use.Females who had a mental health and/or addiction diagnosis were 28 times more likely to use the hospital than undiagnosed females, a relationship 22 times higher than the same one in males, suggesting that males and females vary in their likelihood of hospital usage based on if they have received a diagnosis.This indicates that among opioid users who use hospital services, there is an important interplay between females and status of professional diagnoses for addiction and/or mental health.Future research could examine the sex differences associated with opioid use, hospital use and mental health and/or addiction diagnoses to determine how to best to support varied subpopulations.

Limitations
This analysis had several limitations that should be taken into consideration.Self-report measures are subject to bias and open to interpretation by participants.Since the Alberta Health and Drug Use Survey focused on collecting survey data from individuals actively accessing services and agencies, individuals that were not actively accessing services were not captured within this analysis resulting in a potentially non-representative sample.Similarly, previous research suggests homelessness has been associated with a lower likelihood of seeking treatment, which could also indicate a nuanced subset not covered within this analysis (Galea et al., 2004).
The analytic sample may not be generalizable because participants were excluded from the analytic sample if they: 1) did not identify as either male or female due to low representation of non-binary participants among the collected surveys; 2) only used non-opioid drugs, in order to focus specifically on opioid drug use; and/or 3) could not provide clear answers to the questions, or did not know or refused to answer questions.Finally, while many variables and potential explanatory factors were controlled for or assessed as confounders it is possible that there are additional unobserved explanatory factors not contained within this analysis.

Conclusion
Opioid overdoses in Canada continue to be a significant public health crisis and individuals who are unstably housed are extremely susceptible to overdose.Unstably housed individuals who use opioids are more likely to utilize hospital services, which impacts both their individual health and wellness while having significant economic costs on society.These findings highlight the importance of considering Housing First in conjunction with supervised consumption services as an important part of harm reduction for populations made vulnerable through structural inequities as part of the response to the overdose epidemic.

Ethics approval and consent to participate
Ethics approvals were given by the University of Calgary Conjoint Health Research Ethics Board REB# REB19-2156.Signed and Informed consent was obtained from all individual participants included in the study.

Table 1 .
Variable Definition and Coding

Table 1 .
Variable Definition and Coding 399

Table 2 .
Sample Characteristics by Hospital Use with Pearson Chi-Squared Results (n=432)

How often: feel guilty due to drug use
*p-value for age is a two-tailed t-test.