Council Responds to JAMA Homeless Mortality Report

The January 14 JAMA Internal Medicine report on the epidemic of overdose deaths among clients of the Boston Health Care for the Homeless Program points to critical issues of homelessness, health, and public policy.

  1. Substance misuse is but one of the factors contributing to the 30 year disparity in life expectancy for homeless persons.[1] In this study, cancer and heart disease were the second and third leading causes of death overall, and the most frequent causes for homeless people over 45. Such chronic, often preventable illnesses require the development of more adequate systems of care for people living at the margins of society.
  2. Substance misuse is undoubtedly a major problem affecting the health of people without homes. Misuse of substances is often a causative factor for homelessness and is also a response to the stresses of being homeless, including disparate rates of pain related to high rates of chronic diseases, violent assaults, and accidents.Homelessness magnifies these problems, but misuse of substances is prevalent throughout society, not just at the poorest extreme of the economic order. The federal Substance Abuse and Mental Health Services Administration (SAMHSA) estimates that among uninsured people who earn less than 138% of the federal poverty level (FPL), 14.2% have substance use disorders. For those between 138% and 399% of FPL, 14.6% have substance use disorders. At either income level, persons with substance use disorders are predominantly male, 18-34 years old, non-Hispanic Whites or Blacks.[2]
  3. 80% of the overdose deaths reported in this study involved opioids; 40% involved multiple drugs, often including opioids. Where the type of opioid could be identified, more than twice as many deaths were related to opioid analgesics as opposed to heroin.Opioid overdose deaths are not unique to persons experiencing homelessness, but are epidemic on a national scale, having tripled from 1999 to 2009.[3] In the United States, the rate of past year nonmedical use of prescription pain relievers among those aged 12 or older is 4.6%.Opioids are commonly prescribed as analgesics for pain, but pain is often inadequately assessed. Pain is best assessed in a multidisciplinary clinical setting that integrates primary and behavioral care and that carefully considers the benefits and risks of opiate prescriptions in the context of the patient’s life situation. Primary care practices should be structured to support the assessment and monitoring that is necessary to blunt this epidemic.

    These approaches are described in Wismer, et al., Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain (Nashville: National Health Care for the Homeless Council, 2011).[4] These adapted clinical guidelines are part of an initiative of the Health Care for the Homeless Clinicians’ Network to improve pain management in the unique circumstances of homelessness.

    Among the most promising strategies for the successful use of opioids to treat chronic nonmalignant pain in homeless adults are clear organizational pain policies and procedures; a written, dynamic treatment plan which focuses on functional improvement and holistic care; a signed patient-provider agreement for treatment that specifies mutual responsibilities of providers and patients and the potential risks of treatments; a team approach to care delivery and case conferencing that employs a group medical visit model; and a consistent, nonjudgmental approach to evaluating behaviors.[5]

  4. Substance abuse treatment is already in dreadfully short supply, particularly for persons without health insurance. The Affordable Care Act (ACA) promises greater access to treatment through expansions of Medicaid for the poorest people (at the state option) and through mandatory, subsidized health insurance for people with more means.The $1.8 billion Substance Abuse Prevention and Treatment (SAPT) Block Grant accounts for approximately 42% of substance abuse expenditures by state substance abuse agencies across the country and supported treatment services for approximately 2.3 million client admissions in FY 2010. The pending federal budget sequester would reduce these services by $151.2 million,[6] eliminating almost 200,000 treatment slots and increasing the risk of ongoing substance misuse and overdose deaths.
  5. Federal and state authorities should promote more safe and effective treatments for pain and opiate abuse. In particular, use of buprenorphine should be advanced as an alternative to methadone, which contributed to 31.4% of opioid-related deaths in the United States from 1999 to 2010. Similarly, naloxone should be available to emergency responders or any bystanders who may encounter overdose cases. Access to non-pharmacological treatments for chronic pain, such as cognitive behavioral therapy and physical therapy, should also be increased.
  6. Lack of housing always seriously complicates efforts to treat illnesses, and the provision of permanent supportive housing, with a housing-first approach, will contribute importantly to the mitigation of this epidemic. The reduction of HIV-related deaths reported in this study is a welcome and important indicator of the effectiveness of multifactorial interventions including pharmacological therapies, intensive case management, and housing.

For more information on the JAMA Internal Medicine Report, contact Jessie Gaeta, MD; Medical Director at Boston Health Care for the Homeless Program, (857) 654-1784; or John Lozier, MSSW; Executive Director, NHCHC, (615) 226-2292.

[1] O’Connell JJ. Premature Mortality in Homeless Populations: A Review of the Literature. Nashville: National Health Care for the Homeless Council, Inc., 2005.

[2] Sources: 2008 – 2010 National Survey of Drug Use and Health,  2010 American Community Survey 

[3] Paulozzi LJ, et al. Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. MMWR 60.43 (2010):87-92.

[4] Wismer, et al., Adapting Your Practice: Recommendations for the Care of Homeless Adults with Chronic Non-Malignant Pain. Nashville: National Health Care for the Homeless Council, 2011.

[5] Ibid.

[6] National Association of State Alcohol and Drug Abuse Directors, Inc., “Budget Sequestration and the Substance Abuse Prevention and Treatment (SAPT) BlockGrant”, June 2012