Skip to main content

Advertisement

SpringerLink
Log in

Jail and Emergency Department Utilization in the Context of Harm Reduction Treatment for People Experiencing Homelessness and Alcohol Use Disorder

  • Published:
Journal of Urban Health Aims and scope Submit manuscript

Abstract

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 the 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. The parent RCT showed that HaRT-A precipitated statistically significant reductions in alcohol use, alcohol-related harm, AUD symptoms, and positive urine toxicology tests. This secondary study tested HaRT-A effects on more distal, 6-month pre-to-posttreatment changes on jail and emergency department (ED) utilization. People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. 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. Administrative data on jail and ED utilization were extracted for 6 months pre- and posttreatment. Findings indicated no statistically significant treatment group differences on 6-month changes in jail or ED utilization (ps > .23). Exploratory analyses showed that 2-week frequency of alcohol use was positively correlated with number of jail bookings in the 12 months surrounding their study participation. Additionally, self-reported alcohol-related harm, importance of reducing alcohol-related harm, and perceived physical functioning predicted more ED visits. Future studies are needed to further assess how harm-reduction treatment may be enhanced to move the needle in criminal justice and healthcare utilization in the context of larger samples, longer follow-up timeframes, and more intensive interventions.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.

    Article  Google Scholar 

  2. North CS, Eyrich-Garg KM, Pollio DE, Thirthalli J. A prospective study of substance use and housing stability in a homeless population. Soc Psychiatry Psychiatr Epidemiol. 2010;45(11):1055–62.

    Article  Google Scholar 

  3. Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health, 2016: United States Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2017.

  4. Baggett TP, Chang YC, Singer DE, Porneala BC, Gaeta JM, O’Connell JJ, et al. Tobacco-, alcohol-, and drug-attributable deaths and their contribution to mortality disparities in a cohort of homeless adults in Boston. Am J Public Health. 2015;105(6):1189–97.

    Article  Google Scholar 

  5. Beijer U, Andreasson S, Agren G, Fugelstad A. Mortality and causes of death among homeless women and men in Stockholm. Scand J Public Health. 2011;39(2):121–7.

    Article  Google Scholar 

  6. Nordentoft M, Wandall-Holm N. 10 year follow up study of mortality among users of hostels for homeless people in Copenhagen. British Med J. 2003;327(7406):81–3.

    Article  Google Scholar 

  7. Fitzpatrick KM, Myrstol B. The jailing of America’s homeless: evaluating the rabble management thesis. Crime Delinq. 2011;57(2):271–97.

    Article  Google Scholar 

  8. Holtyn AF, Jarvis BP, Subramaniam S, Wong CJ, Fingerhood M, Bigelow GE, et al. An intensive assessment of alcohol use and emergency department utilization in homeless alcohol-dependent adults. Drug Alcohol Depend. 2017;178:28–31.

    Article  Google Scholar 

  9. Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002;92(5):778–84.

    Article  Google Scholar 

  10. Greenberg GA, Rosenheck RA. Homelessness in the state and federal prison population. Crim Behav Ment Health. 2008;18(2):88–103.

    Article  Google Scholar 

  11. Tsai J, Rosenheck RA. Consumer choice over living environment, case management, and mental health treatment in supported housing and its relation to outcomes. J Health Care Poor Underserved. Nov 2012;23(4):1671–7.

    Article  Google Scholar 

  12. Collins SE, Clifasefi SL, Dana EA, Andrasik MP, Stahl N, Kirouac M, et al. Where harm reduction meets housing first: exploring alcohol's role in a project-based housing first setting. Int J Drug Policy. 2012;23(2):111–9.

    Article  Google Scholar 

  13. Collins SE, Jones CB, Hoffmann G, Nelson LA, Hawes SM, Grazioli VS, et al. In their own words: content analysis of pathways to recovery among individuals with the lived experience of homelessness and alcohol use disorders. Int J Drug Policy. 2016;27:89–96.

    Article  Google Scholar 

  14. Evans J, Semogas D, Smalley JG, Lohfeld L. “This place has given me a reason to care”: understanding 'managed alcohol programs' as enabling places in Canada. Health Place. 2015;33:118–24.

    Article  Google Scholar 

  15. Ezard N, Cecilio ME, Clifford B, Baldry E, Burns L, Day CA, et al. A managed alcohol program in Sydney, Australia: acceptability, cost-savings and non-beverage alcohol use. Drug Alcohol Rev. 2018;37(Suppl 1):S184–94.

    Article  Google Scholar 

  16. Kidd SA, Kirkpatrick H, George L. Getting to know mark, a homeless alcohol-dependent artist, as he finds his way out of the river. Addict Res Theory. 2011;19(2):102–11.

    Article  Google Scholar 

  17. Pauly BB, Gray E, Perkin K, et al. Finding safety: a pilot study of managed alcohol program participants' perceptions of housing and quality of life. Harm Reduct J. 2016;13(1):15.

    Article  Google Scholar 

  18. Tsemberis S, Gulcur L, Nakae M. Housing first, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651–6.

    Article  Google Scholar 

  19. Collins SE, Clifasefi SL, Logan DE, Samples LS, Somers JM, Marlatt GA. Current status, historical highlights, and basic principles of harm reduction. In: Marlatt GA, Larimer ME, Witkiewitz K, editors. Harm reduction: Pragmatic strategies for managing high-risk behaviors. 2nd ed. New York: Guilford Press; 2011. p. 3–35.

    Google Scholar 

  20. Marlatt GA, Witkiewitz K. Harm reduction approaches to alcohol use: health promotion, prevention, and treatment. Addict Behav. 2002;27(6):867–86.

    Article  Google Scholar 

  21. Cherner RA, Aubry T, Sylvestre J, Boyd R, Pettey D. Housing first for adults with problematic substance use. J Dual Diagn. 2017;13(3):219–29.

    Article  Google Scholar 

  22. Clifasefi SL, Malone DK, Collins SE. Exposure to project-based housing first is associated with reduced jail time and bookings. Int J Drug Policy. 2013;24(4):291–6.

    Article  Google Scholar 

  23. Collins SE, Malone DK, Clifasefi SL, Ginzler JA, Garner MD, Burlingham B, et al. Project-based housing first for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511–9.

    Article  Google Scholar 

  24. Larimer ME, Malone DK, Garner MD, et al. Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems. JAMA. 2009;301(13):1349–57.

    Article  CAS  Google Scholar 

  25. Malone DK, Collins SE, Clifasefi SL. Single-site housing first for chronically homeless people. Hous Care Support. 2015;18(2):62–6.

    Article  Google Scholar 

  26. Muckle J, Muckle W, Turnbull J. Operating principles from Ottawa’s managed alcohol program. Drug Alcohol Rev. 2018;37:S140–2.

    Article  Google Scholar 

  27. Pauly B, Vallance K, Wettlaufer A, et al. Community managed alcohol programs in Canada: overview of key dimensions and implementation. Drug Alcohol Rev. 2018;37:S132–9.

    Article  Google Scholar 

  28. Podymow T, Turnbull J, Coyle D, Yetisir E, Wells G. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol. CMAJ. 2006;174(1):45–9.

    Article  Google Scholar 

  29. Stockwell T, Pauly B, Chow C, et al. Does managing the consumption of people with severe alcohol dependence reduce harm? A comparison of participants in six Canadian managed alcohol programs with locally recruited controls. Drug Alcohol Rev. 2018;37:S159–66.

    Article  Google Scholar 

  30. Vallance K, Stockwell T, Pauly B, et al. Do managed alcohol programs change patterns of alcohol consumption and reduce related harm? A pilot study. Harm Reduct J. 2016. https://doi.org/10.1186/s12954-016-0103-4.

  31. Mackelprang JL, Collins SE, Clifasefi SL. Housing first is associated with reduced use of emergency medical services. Prehosp Emerg Care. 2014;18(4):476–82.

    Article  Google Scholar 

  32. Collins SE, Clifasefi SL, Nelson LA, Stanton J, Goldstein SC, Taylor EM, et al. Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder. Int J Drug Policy. 2019;67:24–33.

    Article  Google Scholar 

  33. The McKinney-Vento Homeless Assistance Act. Vol 42 USC § 11302; 2009.

  34. Substance Abuse and Mental Health Services Administration. Enhancing motivation for change in substance abuse treatment: Treatment Improvement Protocol (TIP) Series 35. SAMHSA Publication No. PEP19-02-01-003. Rockville, MD: Substance Abuse and Mental Health Services Administration. 2019. Available at: http://ncadi.samhsa.gov/govpubs/bkd342/35l.aspx. Accessed 9 Nov 2020.

  35. Heather N, Smailes D, Cassidy P. Development of a readiness ruler for use with alcohol brief interventions. Drug Alcohol Depend. 2008;98:235–40.

    Article  Google Scholar 

  36. LaBrie JW, Shiffman JE, Earleywine ME. Performance of alcohol and safer sex change rulers compared with readiness to change questionnaires. Psychol Addict Behav. 2005;19:112–5.

    Article  Google Scholar 

  37. Maisto SA, Krenek M, Chung T, Martin CS, Clark D, Cornelius J. A comparison of the concurrent and predictive validity of three measurs of readiness to change alcohol use in a clinical sample of adolescents. Psychol Assess. 2011;23:983–94.

    Article  Google Scholar 

  38. Bertholet N, Gaume J, Faouzi M, Daeppen J-B, Gmel G. Predictive value of readiness, importance, and confidence in ability to change drinking and smoking. Addict Sci Clin Pract. 2012;7(Suppl 1):A28.

    Article  Google Scholar 

  39. McLellan AT, Kushner H, Metzger D, Peters R. The fifth edition of the addiction severity index. J Subst Abus Treat. 1992;9:199–213.

    Article  CAS  Google Scholar 

  40. Miller WR, Tonigan J, Longabaugh R. The Drinker Inventory of Consequences (DrInC): an Instrument for Assessing Adverse Consequences Of Alcohol Abuse. Test manual (Vol. 4, Project MATCH Monograph Series). Rockville: National Institute on Alcohol Abuse and Alcoholism; 1995.

    Book  Google Scholar 

  41. Ware JE, Kosinski M, Dewey JE. How to Score Version Two of the SF-36 Health Survey. Lincoln: QualityMetric, Inc.; 2000.

    Google Scholar 

  42. Sturm R, Unützer J, Katon W. Effectiveness research and implications for study design: sample size and statistical power. Gen Hosp Psychiatry. 1999;21:274–83.

    Article  CAS  Google Scholar 

  43. Baldassarre M, Caputo F, Pavarin RM, Bossi MM, Bonavita ME, Caraceni P, et al. Accesses for alcohol intoxication to the emergency department and the risk of re-hospitalization: an observational retrospective study. Addict Behav. 2018;77:1–6.

    Article  Google Scholar 

  44. Zhang LD, Norena M, Gadermann A, Hubley A, Russell L, Aubry T, et al. Concurrent disorders and health care utilization among homeless and vulnerably housed persons in Canada. J Dual Diagn. 2018;14(1):21–31.

    Article  Google Scholar 

Download references

Acknowledgments

This work was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to Susan E. Collins (R34AA022077). NIAAA did not have a role in study design; collection, analysis, and interpretation of the data; report writing; or decision to submit the article for publication.

Author information

Authors and Affiliations

  1. University of Washington – Harborview Medical Center, 325 Ninth Ave, Box 359911, Seattle, WA, 98104, USA

    Susan E. Collins, Silvi C. Goldstein, Bow Suprasert, Samantha A. M. Doerr, Joanne Gliane, Clarissa Song, Victoria E. Orfaly, Rddhi Moodliar, Emily M. Taylor & Gail Hoffmann

Authors
  1. Susan E. Collins
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Silvi C. Goldstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Bow Suprasert
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Samantha A. M. Doerr
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joanne Gliane
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Clarissa Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Victoria E. Orfaly
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Rddhi Moodliar
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Emily M. Taylor
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Gail Hoffmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Susan E. Collins.

Ethics declarations

The Institutional Review Board at the University of Washington approved all participant procedures.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Collins, S.E., Goldstein, S.C., Suprasert, B. et al. Jail and Emergency Department Utilization in the Context of Harm Reduction Treatment for People Experiencing Homelessness and Alcohol Use Disorder. J Urban Health 98, 83–90 (2021). https://doi.org/10.1007/s11524-020-00452-8

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11524-020-00452-8

Keywords

Search

Navigation