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What is the current situation regarding illicit substance use and people experiencing homelessness?
As the United States grapples with the fentanyl–fueled third wave of the opioid epidemic, some populations are being disproportionally affected. For example, people experiencing homelessness have been among the most vulnerable to impacts such as overdose. And they are simultaneously very poorly understood. This topic is particularly relevant to Maine because the largely rural setting compounds the difficulty of understanding the magnitude of the issue, as well as the complexities in addressing it.
What does it mean to be an individual experiencing homelessness?
It may seem like defining homelessness would be simple. However, there is ongoing, passionate discussion about what it means to be a person experiencing —or at risk of experiencing—homelessness. Some authorities have a rather strict definition while others take a more holistic view.
- The Department of Housing and Urban Development defines homelessness in two ways
- Experiencing homelessness for 12 consecutive months
- Experiencing homelessness for a total of 12 months with at least four separate occasions over three years
- Some academic and public health officials define homelessness as
- The absence of a physical structure that protects someone from the elements
To acquire community services, families need to provide documentation of housing status and proof of chronic homelessness. Definitions become blurred and folks can be disqualified from programs through activities such as “couch surfing”, staying with friends or family for short periods of time, or having some other means of unstable shelter.
How are persons experiencing homelessness disproportionately impacted by the opioid epidemic?
Much of the data concerning persons experiencing homelessness is collected in urban areas. As seen in the chart below, in Philadelphia, drug-related fatalities among the unhoused have increased from 37% of all deaths among that population to 60% in 2016-2018. Of those that died of an overdose, 86% had opioids in their system and 73% had fentanyl.
One group of researchers found a strong association between housing status and opioid overdose and opioid-related hospital admissions/emergency department visits. They also compared those experiencing poverty and those experiencing homelessness. The results were stunning. Unhoused individuals were 6 times more likely to have poorer opioid-related health outcomes than housed individuals who were also impoverished and they were nearly 7 times more likely to have an opioid-related emergency department visit.
What does homelessness look like in Maine?
On any given day over the past decade, the Department of Housing and Urban Development (HUD) estimates that there are just over 2,000 people experiencing homelessness in Maine. This number, as mentioned above, comes from the federal definition of chronic homelessness and does not take into account persons with unstable housing or who have episodes of acute houselessness.
During 2019, syringe service providers (SSPs) reported to the Maine Center for Disease Control & Prevention that they conducted 5,027 referrals for community housing services from November 1, 2018 to October 31, 2019. Further, 211 reports that from January 29, 2021 to January 28, 2022 they received 11,112 calls for housing and shelter assistance.
All three of these metrics are underreporting the persons experiencing homelessness or unstable housing in the State of Maine as the HUD statistic uses a strict definition for programatic services, the SSP report is representative of the substance use community, and 211 is a vastly underutilized service.
Most imagine homelessness or housing instability as middle-aged folks living in tents located in parks or small green spaces, but a significant portion of housing instability takes place out of view and they are not always adults. According to the 2019 Maine Homelessness Survey: Point in Time Count over 33% of the households who are homeless are families with children. According to the National Center for Homeless Education during the 2017-2018 school year 2,443 Maine students experienced homelessness; approximately 1.4% of the 180,917 the total student population. Of these, 1,478 (60.5%) couched surfed, 596 (24.4%) spent time in shelters, 295 (12.1%) lived unstably in temporary housing, and 74 (3.0%) were unsheltered.
The 2019 Maine Homelessness Survey: Point in Time Count also notes that there is a large racial disparity in who experiences homelessness in the State. For example individuals who are black or African American comprise approximately 1.5% of Maine’s population, however, they make up 26% of the people experiencing homelessness. Further, those who are white, despite being the overwhelming majority of Mainers, comprise only 67% of the homeless individuals in Maine counted in the point in time survey.
Are individuals experiencing homelessness more vulnerable to dying from an opioid overdose?
According to the State Unintentional Drug Overdose Reporting System (SUDORS) database, 78 of the 1,259 opioid deaths in the State of Maine between 2016 through June 2020 were persons experiencing homelessness. This is 6% of the overall opioid deaths. The number and percentage of persons experiencing homelessness who become victims of fatal overdoses in Maine is on the rise. In 2020, 39 of 468 individuals were homeless (8%) and according to the Monthly Maine Overdose Report, from January to November 2021 56 drug deaths out of 578 were persons experiencing homelessness (10%). The data from SUDORS indicated that 85% of opioid overdose deaths in people experiencing homelessness died of acute fentanyl toxicity whereas 76% of housing stable individuals died from fentanyl toxicity. Further, stimulants such as methamphetamine and cocaine were listed as a cause of death in 51% of deaths involving a person experiencing homelessness compared to 34% in those stably housed. This could indicate that individuals experiencing homelessness are less likely to have access to naloxone, fentanyl test strip or other safe use supplies. It could also indicate that persons experiencing homelessness are more likely to have untreated conditions that can increase the likelihood of experiencing a fatal overdose. As seen in the charts below, deaths in Maine involving both a stimulant and fentanyl is rising as is the percentage of drug deaths caused by fentanyl.
Source: Rural Drug and Alcohol Research Team, Margaret Chase Smith Policy Center, University of Maine.
How can the cycle of homelessness be broken?
As discussed above, homelessness can affect a wide range of people and therefore a range of services are needed to adequately address those needs. A veteran experiencing homelessness, potentially exacerbated by post-traumatic stress disorder, will likely need different services than a seventeen-year-old that escaped a dangerous homelife but has nowhere to go for the long-term. To respond to this diversity in need, various services around Maine have emerged to provide support and skill-building so people are given a better chance to secure stable housing and employment.
What is the State of Maine doing to address the opioid-related health disparities among persons experiencing homelessness?
There are several programs that intersect with the vulnerable population of folks experiencing homelessness. For example local syringe service programs report to researchers at the Margaret Chase Smith Policy Center at the University of Maine that up to 85% of their clients are folks experiencing unstable housing or homelessness. The State of Maine has expanded syringe service programs throughout the state since 2019.
Another unique initiative which provides outreach to the community of folks experiencing homelessness and substance use disorder is the Overdose Prevention Through Intensive Outreach Naloxone and Safety (OPTIONS) initiative (https://knowyouroptions.me) which aims to improve the health of Mainers using substances through harm reduction strategies and helping them on the road to recovery.
OPTIONS liaisons are licensed behavioral health clinicians who are embedded within local law enforcement agencies in every county across Maine. Liaisons work alongside their first responder counterparts to:
- Engage in post-overdose followup and help with referrals.
- Conduct proactive outreach with at-risk communities.
- De-escalate behavioral health crises when possible.
- Provide short-term counseling interventions when appropriate.
Each OPTIONS liaison serves the entire county in which they are located. As part of the OPTIONS liaison initiative, the Office of Behavioral Health and the Maine Center for Disease Control and Prevention are working to better integrate the varying levels of support services in each county. These services include Syringe Access Programs, naloxone distribution, Recovery Centers, medication for opioid-use disorder, food and housing support among others.
Liaisons across the State of Maine from Aroostook to York counties are serving folks who are experiencing homelessness. The chart below shows the number of people interacting with OPTIONS liaisons that have stable housing, are unstably housed, or who are homeless. As the chart shows, a majority of folks referred to OPTIONS liaisons for service referrals as unstably housed or experiencing homelessness. This indicates both the connection between the population of persons experiencing homelessness and the population of those suffering from negative opioid-related health outcomes but also shows the efficacy of OPTIONS liaisons at reaching Maine’s most vulnerable citizens.
Source: Rural Drug and Alcohol Research Team, Margaret Chase Smith Policy Center, University of Maine.
Where can I find information about local emergency housing shelters?
The following dashboard by the Homeless Shelter Directory provides information about shelters in Maine. Though the shelters listed on the site are all emergency shelters, some a general homeless shelters or transitional housing opportunities as well.