The Mischaracterized Relationship Between Drug Use and Homelessness

    Six months ago Jonny Brown admits he was in a dark place. Addicted to drugs, he’d lost his house and was sleeping rough.”

    It’s the lead to a million identically framed articles implying that drug addiction causes homelessness—and therefore, that avoiding drug use might prevent it.

    The media trope both reflects and fuels a common belief. A survey of 25 American cities by the United States Conference of Mayors in 2008, the year of the last financial crash, found that 68 percent of responding officials considered “substance abuse” to be the main cause of homelessness among single adults and unaccompanied youth. And indeed, this is how some people who use drugs and are homeless see their own experience.

    In March, one week before schools and non-essential businesses were shut in response to the pandemic and most of us went into near-lockdown, I spoke with Snickers, a 33-year-old Toronto woman, outside the tarp-covered tent in the backyard of Sanctuary, a local charitable organization, where she was living with her partner while trying to get into social housing. “I’ve been on the streets eight years, due to addictions,” she said. “My life went spiralling out of control and I lost myself.”

    “Too much abuse going on. And it’s from people who were supposed to protect me, to love me, and they were doing me harm.”

    On the other hand, her original choice to leave home and her native Saskatchewan related to abuse she experienced that pre-dated her drug use. “Too much abuse going on,” she explained. “And it’s from people who were supposed to protect me, to love me, and they were doing me harm.”

    “I believe I started [using drugs like crack cocaine, crystal meth, fentanyl and alcohol] for a quick-fix Band-Aid to numb and mask what I’m really feeling inside,” Snickers said. “It’s able to mask and help me cope and live a daily normal life.”

    Media framing nonetheless promotes a one-way understanding of the relationship between drug use and homelessness: Take this January article describingan almost constant presence of people who are drug addicted or mentally ill in the city’s downtown” in London, Ontario.

    The writer describes “people who seem trapped in a marginal existence in spite of the millions spent trying to save them.” He doesn’t interview any of these inconvenient people, but does quote a resident whose brother has addiction and experienced a period of homelessness. The journalist sums up that complex tale, which includes intergenerational poverty, as “He got hooked on drugs and became homeless.”

    Such persistent stereotypes inflate the public perception of drug use among unhoused people far beyond reality, and suggest that illicit drug use has only one trajectory: the downward spiral. At the same time, it is true that there is a higher prevalence of substance use issues among homeless people than in the population as a whole. According to US Substance Abuse and Mental Health Services Administration figures last updated in 2011, 34.7 percent of “sheltered” homeless adults had “chronic substance use issues.”

     

    What the Research Shows

    In this context, researchers have made many attempts to better understand any causal relationship between use, or problematic use, of drugs and literal homelessless (as opposed to housing insecurity). This research is global and involves many different methodologies, populations and substances. And the findings, as one might expect given the complexities, sometimes seem contradictory.

    In a 2009 structured survey of 489 homeless people in London, England, for example, 63 percent of respondents identified substance use (including alcohol) as one of the reasons they became homeless. However, 80 percent reported starting to use at least one new drug since losing housing.

    By contrast, when researchers in New Haven, Connecticut, asked homeless participants in 2006 what caused their homelessness, just 25 percent of respondents attributed it to drugs, most often cocaine. 

    Meanwhile, Chris Chamberlain and Guy Johnson, in Australia, found in a 2008 study of 4,291 homeless social services clients in Melbourne that 43 percent had substance use issuesbut in two-thirds of cases, they developed those problems only after becoming homeless. The study also found that younger people were more likely to have experienced the issues in that order: first the streets, then the problematic drug use.

    Contrary to their expectations, the researchers did not in fact find “substance abuse” to be a direct cause of homelessness.

    Most pertinently, a 2002 study of 481 people either homeless or “at risk” of homelessness in Cook County, Illinois, by Jonathan Vangeest and Timothy Johnson, used a type of analysis that tests whether hypothesized causal relationships really are causal.

    Contrary to their expectations, the researchers did not in fact find “substance abuse” to be a direct cause of homelessness. Neither did it turn out to prevent accumulation of “human capital” (“assets,” such as education or employment) that might be presumed to protect against homelessness: Education levels were similar among literally homeless and at-risk respondents, so having a higher education did not protect struggling people from that final push into literal homelessness.

    Rather, the researchers found, problematic substance use plays “a critical role” in what they called “disaffiliation”—the weakening of people’s social and institutional connections such as belonging to a church, having a network of friends, or having work and business relationshipsmaking them more vulnerable to homelessness. (Even here, however, we should note that societal and institutional stigmatization of drug use, beyond any consequences of drug use itself, are at play; and that homeless people do retain supportive friends and networks of various kinds.)

    Vangeest and Johnson’s work reflects much of what has been found in research on the homelessness and drug use question that goes all the way back to the 1930s.

    “Substance use can play a role at each point in the continuum”, said Kelly Doran, a researcher and ER physician with NYU Langone Health in New York City. “In my review of the evidence I feel pretty strongly that there’s good evidence for both directions [of causality],” she told Filter. “The best way to think of it is maybe a vicious cycle.”

     

    “It Wasn’t Just One Thing”

    Drug use that picks up when a person loses housing, or that intensifies as their living situation gets more precarious, is a response to circumstancesa possibly-practical reaction to emotional stress.

    “When you’re unhoused it causes a lot of distress, which causes drug use,” said Sterling Johnson, a Philadelphia-based advocate for the human rights of people who use drugs. He explained that when you use drugs during homelessness, a form of societal abandonment, “You’re responding to a really traumatic situation in a reasonable fashion.”

    There are practical reasons, too, for homeless people’s specific choices of drugs. Stimulants, for example, may help people to stay awake at night when it is most unsafe to be unaware of one’s surroundings. Alcohol or drugs like opioids can reduce the experience of cold or provide a sense of comfort.

    But pre-existing substance use, particularly addiction, can also make someone more vulnerable to homelessness. Experiences include being kicked out of the house by a partner or parent for using drugsor having trouble getting or keeping a job, due to employer drug testing or to behaviors linked with substance use disorders. Again, society’s reactions to drugs cause these problems to a significant degree.

    Family members probably have a vested emotional interest in considering drugs, rather than relationships, to be the cause of their loved one sleeping rough.

    Brooke Feldman, a social worker and harm reduction advocate in Philadelphia, described seeing people with drug issues finding it harder and harder to find family members who will take them in. This is sometimes fueled by a belief, not based in fact, that people with addiction need to “hit rock bottom” by being kicked out of their families before they will recover. “You can’t come here until you stop using drugs,” she said they may be told. And family members probably have a vested emotional interest in considering drugs, rather than relationships, to be the cause of their loved one sleeping rough.

    Dr. Doran pointed out that most existing research on homelessness and substance use is not designed in such a way that you can easily tease out causation. Among the very long set of research articles in a literature review that she created and shared with Filter, the study populations and methodologies vary widely.

    Dr. Stefan Kertesz, a physician who provides primary care and addiction treatment to homeless veterans in Birmingham, Alabama, also shared his own annotated bibliography on the subject with Filter. His review involves teasing out the important findings in 30 sources, dating back to 1935. Again, though, it is difficult to compare the various studies.

    Without closer, probing examination of the individual life trajectories of people experiencing homelessness, he notes, a correlation between being on the street and using drugs could mean many different things.

    In a qualitative study presented in part at the Inebria addiction research conference in Hamburg, Germany in September 2019, Dr. Doran’s team tried to do exactly that. They interviewed a selected group of mostly men, of various ethnic backgrounds, who had become homeless in the past six months and presented to an emergency department in NYC.

    Questions in the one-on-one, in-depth interviews included whether and how substance use influenced their loss of housing. Respondents indicated multiple relationships between drug use and homelessnessthe first paper coming out of this study is titled “It Wasn’t Just One Thing.”

    In Doran’s team’s analysis of the interviews, they found common causal factorssuch as isolation and what they call “interpersonal factors,” like family discord—for both homelessness and problematic drug use. Homelessness sometimes exacerbates (due to depression, for example) and sometimes reduces (due to lack of time and safe space to use, for example) an individual’s existing drug use, they found. And drug use sometimes opens pathways out of homelessness such as access to supportive housing programs, and sometimes poses a barrier to getting into housing.

    Like Doran’s team, Sutherland and Locke identified a complex relationship between alcohol use and homelessness, also pointing to the often-ignored relevance of big socio-economic changes.

    Doran’s study harks back to Edwin Sutherland and Harvey Locke’s Depression-era, qualitative study of homeless men in Chicago shelterspublished as a book, titled Twenty Thousand Homeless Men: A Study of Unemployed Men in the Chicago Shelters. Like Doran’s team, Sutherland and Locke identified a complex relationship between alcohol use and homelessness, also pointing to the often-ignored relevance of big socio-economic changes, such as a shift to precarious work.

    Dr. Kertesz, in his annotations on this work, juxtaposes it with the US Bureau of the Census’s 1996 National Survey of Homeless Assistance Providers and Clients (NSHAPC). Of the latter, he writes, “A notable discrepancy exists between the low proportion of currently homeless individuals who cite substance abuse (drinking or drugs) as one of the top 3 reasons for leaving their home, and [the] high proportion of those individuals who attest to having a problem with substance abuse.”

    As Vangeest and Johnson wrote in 2002, “individuals who are less involved in a collective existence (i.e., working, raising a family, etc.) feel its influences less strongly and are less inclined toward normative behavior. Homelessness thus is, in part, the result of a breakdown in the social bonds necessary for human community. Substance abuse may play a critical role in this breakdown, negatively influencing social as well as institutional bonds.”

     

    The Need to See a Bigger Picture

    Once housing is lost, rules against drug use erect severe barriers to getting it back. Feldman said that in Philadelphia, as in much of the rest of the US, admission to recovery houses or other transitional housing typically requires abstinenceand only the small number of facilities regulated by the city are even mandated to allow medications like methadone and buprenorphine, despite their being shown robustly to prevent overdose death. As a result, there are few safe options for leaving homelessness if you are dependent on opioids or other drugs and unwilling to take your chances with abstinence until your life is more stable.

    Any causality is deeply complicated by prohibition and the structures in which it developed. These include structural racism and classism.

    The impact that the use of a particular substance has on a person’s risk of eventual homelessness clearly varies hugely by social, economic and legal contexts. These include local cultures; laws and their enforcement; the composition of the illicit drug supply; the availability of prescription alternatives; and racism (in the 2002 Cook County study, 64 percent of respondents were African American, and thus systemic as well as individual racism inevitably played a role at every juncture). Each will affect the likelihood of substance use preventing employment, bank loans, apartment rentals and other housing options, or resulting in incarceration.

    Any causality is deeply complicated by prohibition and the structures in which it developed. These include structural racism and classismwhich might, for example, push people of a particular race, ethnicity or socio-economic class (or even gender) into neighborhoods subjected to targeted law enforcement. Economic factors include the rise of the gig (or precarious work) economy and a housing crisisresulting from commodification of real estate and multilateral agreements that privilege the rights of those who want to profit from housing over those who need affordable homes.

    Housing, before around the 1980s, had less value as an investment. Then came the deregulation of housing markets, the advent of mortgage-backed securities, and trade liberalization that subsumed US states’ right to set housing policy to investor rights, guaranteed in international trade agreements.

    The UN Special Rapporteur on Housing, in a 2017 report that you should absolutely read if you are not wealthy, need a home and enjoy getting really angry, described: 

    “Structural changes in housing and financial markets and global investment whereby housing is treated as a commodity, a means of accumulating wealth and often as security for financial instruments that are traded and sold on global markets.”

    As the UN report says, the changes that have occurred since the ‘80s have in recent years led to a profound reshaping of economies and a dramatic rise in evictions, with austerity measures imposed after the financial crisis of 2008 resulting in cuts to programs that previously mitigated the impact of this shift. Parties that campaign on austerity or small government typically attack protections for the marginally housed and lend support to gentrification when they form governments. 

    We might identify the most important causal factor for both trends as the same: right-wing politics.

    This pushes people already on the edge over that edge and into homelessness. Drugs are certainly not required, but they, and their stigmatization and prohibition, can increase vulnerabilities for all the reasons we’ve discussed. 

    Use of some drugs in North American cities appears to be on the rise, in tandem with a rise in both homelessness and precarious housing situations. But rather than seeing problematic drug use as causing homelessness or homelessness as causing drug use, we might identify the most important causal factor for both trends as the same: the right-wing politics that hurt people’s ability to afford daily needs, secure steady employment, afford rent, be part of a stable rather than transient community, and enter an increasingly tight and expensive rental housing market.

    Brooke Feldman noted that once everyone has turned their back on a person who uses drugs, homelessness encampments may provide a sense of community, in which the causes that brought you there are really not the point. Despite enduring the most distressing life circumstances, at least you are with, in her words, “people who didn’t judge them, didn’t shame them, are not going to treat me like a piece of shit for being the way I am”. 

    Encampments—such as those that have rapidly grown in Toronto in light of the pandemic since I began working on this article—also provide, compared to crowded shelters, the possibility of social distancing for people without homes. This article is the first in a three-part series, and Part 2—concerning encampments and the criminalization of homelessness—is suddenly more urgent than ever.


     

    Photograph by Helen Redmond

    • Carlyn Zwarenstein

      Carlyn is a freelance journalist based in Toronto. She writes about pain, struggle, injustice, drugs, exile, suffering—and how to make it better. Her work has appeared in publications including the Washington Post, the Guardian, the Globe and Mail and many others. Her memoir, Opium Eater: The New Confessions, was a Globe and Mail Best 100 book of 2016. An expanded version, incorporating journalism about substance use, pain, harm reduction and what people need to be well, will be published in 2021.

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