Patients with opioid use disorder (OUD) experiencing homelessness face an increased risk of opioid overdose and death, compared with patients with OUD who are housed. Unfortunately, those lacking housing are less likely than those with housing to enter and stay in methadone maintenance treatment (MMT) programs—programs they urgently need.
A new study funded in part by the National Institutes of Health and the National Science Foundation shines light on the fact that many of these patients leave treatment early or fail to enter methadone treatment at all. At traditional MMT programs, patients can be discharged from treatment for not being able to pay or not following stringent behavioral codes. For example, daily attendance requirements can be difficult to adhere to for people without cars or whose sleeping location often changes.
And that’s where low-barrier-to-treatment-access programs come in, for these programs help remove hurdles to entering or remaining in MMT.
The Substance Abuse and Mental Health Services Administration (SAMHSA) defines patient stability as a characteristic of patients who have completed at least 60 days in treatment, and whose medical record fully documents eight specific criteria, among them negative toxicology test results for 60 days and absence of serious behavioral problems.
MMT programs may misinterpret “patient stability,” thinking it means “stable housing.” If so, they may deny take-homes and other services, thus limiting patients’ access and retention.
“Administrative discharge” is a term that accounts for 65% to 75% of early terminations in MMT. Reasons cited for these discharges include patients’ failure to pay for services received; or a violation of clinic policies, such as failing a requirement for negative urine drug screens; or patients’ failure to meet clinic attendance requirements that are more demanding than those allowed by the federal government.
Such examples illustrate why low-barrier methadone programs make such a difference to patients who are seeking help. These programs are more flexible than standard MMT programs, and their attendance policies are less rigid. Abstaining from substance use isn’t a strict requirement for entering or staying in low-barrier treatment, or for refilling medications.
Until now, few studies have looked at the interplay between patient characteristics and retention in MMT programs, based on patients’ housing status. This study, published February 25 in the Journal of Substance Abuse Treatment, explores the topic in depth. Details of the study are presented below.
This was a cohort study, a retrospective chart review of consecutive patients enrolled in low-barrier MMTs. The period covered was April to December 2017. Treatment was administered at the APT Foundation, a not-for-profit, community-based organization affiliated with Yale School of Medicine, which operates four outpatient MMT clinics in southern New England. Conducting the study were investigators from Yale, the University of Washington, the University of North Carolina at Chapel Hill, and the APT Foundation.
Unhoused vs. Housed
To distinguish between “homeless” (“unhoused”) and “housed,” patients were asked, “Where did you sleep in the past 30 days?” on the 24-item Behavior and Symptom Identification Scale (BASIS-24). Those who selected “Shelter/street” were categorized as “unhoused.” Those selecting “Apartment or House” were considered “housed.”
Of 598 initial patients, excluded were ten who indicated they did not read or write English, and 100 who described their status as neither housed nor unhoused. The remaining 488 patients became the study population.
Characteristics at Study Entry
- 46 patients (9.4%) were experiencing homelessness
- 442 patients (90.6%) were housed
Homeless Group, Compared With the Housed Group
- Lower rates of recent employment
- Higher rates of social isolation, trauma, recent cannabis use, psychiatric distress, and chronic pain (all values for these categories were statistically significant [P < 0.01]).
At the end of one year, only about half of all patients (51.8%) were still in treatment: 53.8% of the housed group and 32.6% of the unhoused group. Most strikingly, by year end, treatment discontinuation in the homeless group was increased by 69%, compared to the housed group. (Following state regulations, patients who missed 30 consecutive appointments were discharged from the study and considered “discontinued” from treatment.)
After controlling for multiple testing, the only other variables with pertinent findings were recent cannabis use, associated with higher odds of retention; and volunteering, associated with lower odds of retention.
The authors noted two main findings from the study:
- At baseline, compared to housed patients, those without homes had
- Lower rates of recent employment
- Higher rates of social isolation, physical assault, sexual assault, recent cannabis use, and current chronic pain
- Higher levels of overall psychiatric distress
- The unhoused were significantly less likely than the housed to still be in treatment at 12 months. After statistical analysis, homelessness was associated with a 69% increase in treatment discontinuation at one year.
The authors commented that patients entering MMT while experiencing homelessness have multiple clinical vulnerabilities, and face an increased risk for discontinuing treatment at the end of one year. Low-barrier MMT programs are an important platform for identifying and addressing the vulnerabilities associated with homelessness.
Gaeta Gazzola M, Carmichael ID, Madden LM, et al. A cohort study examining the relationship among housing status, patient characteristics, and retention among individuals enrolled in low-barrier-to-treatment-access methadone maintenance treatment [published online ahead of print, 2022 Feb 25]. J Subst Abuse Treat. 2022;108753. doi:10.1016/j.jsat.2022.108753