Open Access Open Access  Restricted Access Subscription or Fee Access

Opioid use disorder and homelessness in the Veterans Health Administration: The challenge of multimorbidity

Theddeus Iheanacho, MD, Elina Stefanovics, PhD, Robert Rosenheck, MD

Abstract


Objective: The aim of this study is to estimate the prevalence and sociodemographic and clinical correlates of opioid use disorder (OUD), a major cause of morbidity and mortality in the United States, among homeless veterans nationally in the Veterans Health Administration (VHA).

Design: Administrative data on 256,404 veterans who were homeless and/or had OUD in fiscal year 2012 were analyzed to evaluate OUD as a risk factor for homelessness along with associated characteristics, comorbidities, and patterns of service use. Bivariate analyses and logistic regression were used to compare homeless veterans with OUD to veterans with OUD but no homelessness and homeless veterans with no OUD.

Results: Altogether 17.9 percent of homeless VHA users were diagnosed with OUD and 34.6 percent of veterans with OUD were homeless. The risk ratio (RR) for homelessness among veterans with OUD was 28.7. Homeless veterans with OUD, compared to nonhomeless veterans with OUD showed extensive multimorbidity with greater risk for HIV (RR = 1.57), schizophrenia (RR = 1.62), alcohol use disorder (RR = 1.67), and others. Homeless veterans with OUD also showed more multimorbidity and used more services than homeless veterans without OUD. Homeless and nonhomeless OUD veterans used opiate agonist therapy at similar, but very low rates (13 and 15 percent).

Conclusions: OUD is a major risk factor for homelessness. Homeless veterans with OUD have high levels of multimorbidity and greater service use than veterans with either condition alone. Tailored, facilitated access to opioid agonist therapy may improve outcomes for these vulnerable veterans.


Keywords


opioid use disorder, homeless, veterans, opioid agonist therapy

Full Text:

PDF

References


Centers for Disease Control and Prevention: Vital signs: Overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011; 60: 1487-1492.

Manchikanti L, Helm S, 2nd, Fellows B, et al.: Opioid epidemic in the United States. Pain physician. 2012; 15: 2150-1149.

Webster LR, Cochella S, Dasgupta N, et al.: An analysis of the root causes for opioid-related overdose deaths in the United States. Pain Med. 2011; 12: S26-S35.

Substance Abuse and Mental Health Services Administration: Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012.

Han B, Compton WM, Jones CM, et al.: Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015; 314: 1468-1478.

Saha TD, Kerridge BT, Goldstein RB, et al.: Nonmedical prescription opioid use and DSM-5 nonmedical prescription opioid use disorder in the United States. J Clin Psychiatry. 2016; 77: 772-780.

Degenhardt L, Charlson F, Mathers B, et al.: The global epidemiology and burden of opioid dependence: results from the global burden of disease 2010 study. Addiction. 2014; 109: 1320-1333.

Jones CM: Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers–United States, 2002–2004 and 2008–2010. Drug Alcohol Depend. 2013; 132: 95-100.

Calcaterra S, Glanz J, Binswanger IA: National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999–2009. Drug Alcohol Depend. 2013; 131: 263-270.

Degenhardt L, Bucello C, Mathers B, et al.: Mortality among regular or dependent users of heroin and other opioids: A systematic review and meta-analysis of cohort studies. Addiction. 2011; 106: 32-51.

Greenberg GA, Rosenheck RA: Mental health correlates of past homelessness in the National Comorbidity Study Replication. J Health Care Poor Underserved. 2010; 21: 1234-1249.

Tsai J, Rosenheck RA: Risk factors for homelessness among US veterans. Epidemiol Rev. 2015; 37: 177-195.

Robertson MJ, Zlotnick C, Westerfelt A: Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997; 87: 221-228.

Wenzel SL, Burnam MA, Koegel P, et al.: Access to inpatient or residential substance abuse treatment among homeless adults with alcohol or other drug use disorders. Med Care. 2001; 39: 1158-1169.

Tucker JS, Wenzel SL, Golinelli D, et al.: Predictors of substance abuse treatment need and receipt among homeless women. J Subst Abuse Treat. 2011; 40: 287-294.

Lebrun-Harris LA, Baggett TP, Jenkins DM, et al.: Health status and health care experiences among homeless patients in federally supported health centers: Findings from the 2009 patient survey. Health Serv Res. 2013; 48: 992-1017.

Baggett TP, Hwang SW, O’Connell JJ, et al.: Mortality among homeless adults in Boston: Shifts in causes of death over a 15-year period. JAMA Internal Med. 2013; 173: 189-195.

Wagner TH, Harris KM, Federman B, et al.: Prevalence of substance use disorders among veterans and comparable nonveterans from the National Survey on Drug Use and Health. Psychol Serv. 2007; 4: 149-157.

Tsai J, Kasprow WJ, Rosenheck RA: Alcohol and drug use disorders among homeless veterans: Prevalence and association with supported housing outcomes. Addictive Behav. 2014; 39: 455-460.

Schuckit MA: Treatment of opioid-use disorders. New Engl J Med. 2016; 375: 357-368.

Hwang SW, Burns T: Health interventions for people who are homeless. Lancet. 2014; 384: 1541-1547.

American Psychiatric Association: DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, Text Revision. Washington, DC: American Psychiatric Association, 2000: 75.

Compton WM, Dawson DA, Goldstein RB, et al.: Crosswalk between DSM-IV dependence and DSM-5 substance use disorders for opioids, cannabis, cocaine and alcohol. Drug Alcohol Depend. 2013; 132: 387-390.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®). Washington, DC: American Psychiatric Pub, 2013.

Charlson ME, Pompei P, Ales KL, et al.: A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987; 40: 373-383.

Needham DM, Scales DC, Laupacis A, et al.: A systematic review of the Charlson comorbidity index using Canadian administrative databases: A perspective on risk adjustment in critical care research. J Crit Care. 2005; 20: 12-19.

Quan H, Li B, Couris CM, et al.: Updating and validating the Charlson comorbidity index and score for risk adjustment in hospital discharge abstracts using data from 6 countries. Am J Epidemiol. 2011; 173: 676-682.

Morrill R, Cromartie J, Hart L: Metropolitan urban and rural commuting areas: Toward a better depiction of the U.S. settlement system. Urban Geography. 1999; 20: 727-748.

Cohen J: Statistical Power Analysis for the Behavioral Sciences. New York: Routledge Academic, 2013.

Minkoff K: Best practices: Developing standards of care for individuals with co-occurring psychiatric and substance use disorders. Psychiatric Serv. 2001; 52: 597-599.

Sacks S, Ries RK: Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) Series 42. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005.

Edens EL, Kasprow W, Tsai J, et al.: Association of substance use and VA service-connected disability benefits with risk of homelessness among veterans. Am J Addict. 2011; 20: 412-419.

Boyd CM, Martin Fortin M: Future of multimorbidity research: How should understanding of multimorbidity inform health system design? Public Health Rev. 2010; 32: 451-474.

North CS, Brown ES, Pollio DE: Expanded conceptualization of multimorbidity to encompass substance use disorders and other psychiatric illness. Ann Clin Psychiatry. 2016; 28: 182-188.

Tinetti ME, Fried TR, Boyd CM: Designing health care for the most common chronic condition—Multimorbidity. JAMA. 2012; 307: 2493-2494.

Connery HS: Medication-assisted treatment of opioid use disorder: Review of the evidence and future directions. Harvard Rev Psychiatry. 2015; 23: 63-75.

Oliva EM, Trafton JA, Harris AH, et al.: Trends in opioid agonist therapy in the Veterans Health Administration: Is supply keeping up with demand? Am J Drug Alcohol Abuse. 2013; 39: 103-107.

Green CA, McCarty D, Mertens J, et al.: A qualitative study of the adoption of buprenorphine for opioid addiction treatment. J Subst Abuse Treat. 2014; 46: 390-401.

Oliva EM, Maisel NC, Gordon AJ, et al.: Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psychiatry Rep. 2011; 13: 374-381.

Oliva EM, Nevedal A, Lewis ET, et al.: Patient perspectives on an opioid overdose education and naloxone distribution program in the US Department of Veterans Affairs. Substance Abuse. 2016; 37: 118-126.

Irvin JE, Bowers CA, Dunn ME, et al.: Efficacy of relapse prevention: A meta-analytic review. J Consult Clin Psychol. 1999; 67: 563-570.

Hendershot CS, Witkiewitz K, George WH, et al.: Relapse prevention for addictive behaviors. Substance Abuse Treat Prev Policy. 2011; 6: 17.

Krupitsky E, Nunes EV, Ling W, et al.: Injectable extended-release naltrexone for opioid dependence: A double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011; 377: 1506-1513.

Babor TF, McRee BG, Kassebaum PA, et al.: Screening, Brief Intervention, and Referral to Treatment (SBIRT) toward a public health approach to the management of substance abuse. Substance Abuse. 2007; 28: 7-30.

Cunningham RM, Bernstein SL, Walton M, et al.: Alcohol, tobacco, and other drugs: Future directions for screening and intervention in the emergency department. Acad Emerg Med. 2009; 16: 1078-1088.

Young MM, Stevens A, Galipeau J, et al.: Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: A systematic review. Syst Rev. 2014; 3: 50.

Madras BK, Compton WM, Avula D, et al.: Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: Comparison at intake and 6 months later. Drug Alcohol Depend. 2009; 99: 280-295.

Miller WR, Benefield RG, Tonigan JS: Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. J Consul Clin Psychol. 1993;61:455-461.

Kasprow WJ, Rosenheck RA: Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization. Psychiatric Serv. 2007; 58: 929-935.

Mares AS, Kasprow WJ, Rosenheck RA: Outcomes of supported housing for homeless veterans with psychiatric and substance abuse problems. Mental Health Serv Res. 2004; 6: 199-211.

Cheng A-L, Lin H, Kasprow W, et al.: Impact of supported housing on clinical outcomes analysis of a randomized trial using multiple imputation technique. J Nerv Ment Dis. 2007; 195: 83-88.

O’Toole TP, Johnson EE, Borgia ML, et al.: Tailoring outreach efforts to increase primary care use among homeless veterans: Results of a randomized controlled trial. J Gen Intern Med. 2015; 30: 886-898.

Mohamed S, Neale M, Rosenheck RA: VA intensive mental health case management in urban and rural areas: Veteran characteristics and service delivery. Psychiatric Serv. 2009; 60: 914-921.

Iheanacho T, Manhapra A: Developing a non-office based buprenorphine treatment program for homeless adults with opioid dependence. Am J Addict. 2016; 25: 342-343.

Tsai J, Mares AS, Rosenheck RA: A multisite comparison of supported housing for chronically homeless adults: “Housing first” versus “residential treatment first.” Psychol Serv. 2010; 7: 219-232.

D’onofrio G, O’Connor PG, Pantalon MV, et al.: Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA. 2015; 313: 1636-1644.

McCance-Katz EF, Sullivan LE, Nallani S: Drug interactions of clinical importance among the opioids, methadone and buprenorphine, and other frequently prescribed medications: A review. Am J Addict. 2010; 19: 4-16.

Ruzek JI, Karlin BE, Zeiss A: Implementation of evidence-based psychological treatments in the Veterans Health Administration. In McHugh RK, Barlow DH (eds.): Dissemination and Implementation of Evidence-Based Psychological Interventions. New York, NY: Oxford University Press., 2012: 78-96.




DOI: http://dx.doi.org/10.5055/jom.2018.0447

Refbacks

  • There are currently no refbacks.
This site uses cookies to maintain session information critical to the user's experience and environment on this system. Click "Accept Cookies" to continue.
For more details please visit our privacy statement at: Privacy & GDPR