Over the past decade, drug use in the US has risen dramatically, with heroin use reaching epidemic proportions.
The country’s policy for combating abuse has involved incarceration, abstinence-only treatment, or prescribing medication, like methadone or buprenorphine. While some of these responses have helped many, history and recent statistics have shown these are not long term solutions.
Currently, drug treatment, which receives a fraction of the public funds allotted to fighting drug trafficking (the “War on Drugs”), is largely focused on abstinence-only programs. Rarely does it acknowledge that not all drug use is problematic. Abstinence may be a desired goal for some drug users, but for other users, learning moderation allows them to function. In 2010, when one innovative director of a large New York City drug treatment center introduced “moderation management” as a choice among treatment plans, he lost his job. A few years later moderation was proposed by another prominent leader in drug treatment under a new name: Integrative Harm Reduction Therapy.
The term “harm reduction” refers to practical strategies aimed at reducing the harm caused by drug use. It accepts that drug use is a complex issue with a wide range of behaviors, not all of which are problematic. It emphasizes quality of life and social inclusion, not exclusion. It’s an approach that takes into account the individual user – his or her race, class, gender, and age. While respecting the dignity of drug users, it does not minimize the real harm associated with problematic drug use behavior.
Housing First: a harm reduction model
One harm reduction strategy that challenges traditional drug treatment is the “Housing First” model. However, drug use was not the problem it was originally intended to address.
Housing First was founded and developed by Dr. Samuel Tsemberis in 1992 in New York. His approach provided immediate housing to homeless people with mental health illnesses, whether or not they were abusing drugs or seeking treatment. This policy was in direct opposition to traditional homeless services that adhere to a “Treatment First” model, where a homeless person needs to abstain from using or enroll in a drug rehabilitation program in order to qualify for any type of housing.
Comparison studies of Housing First and Treatment First models consistently found that the homeless using Housing First had longer terms of stable housing than those using Treatment First, with no difference in their levels of drug use. This was the case for all the varying forms of Housing First models, whether they were group homes or single homes.
Morerecentstudies showed that Housing First participants had lower rates of substance use than those forced to go to treatment prior to receiving housing. Public costs for emergency shelters, emergency department visits, hospital health care, and incarceration all fell when Housing First was introduced in Seattle and San Franscisco.
While Housing First is not a panacea for substance abuse, it addresses the failures of abstinence-based housing services, such as chronic relapse and return to homelessness.
Critics of the Housing First model point out that the program relies on accepting only homeless people who have a diagnosed mental health illness and are eligible for social security income supplement (SSI). Funds from an individual’s SSI are required to supplement the costs of housing, yet many of the homeless with substance abuse problems are not eligible for SSI, making them ineligible for Housing First.
However, a 2013 study conducted by Susan Collins in Seattle looked at a group housing project that did not require SSI. This group housing project placed chronically homeless people with severe alcohol problems in group housing with no alcohol use restrictions. She found a significant majority stayed housed, and that active drinkers were more likely to remain in housing than nondrinkers.
Housing First highlights the importance of an individual’s social environment. Among the chronically homeless, drug use is often not the problem, but rather a means to cope with homelessness. Likewise, for many users, drug use isn’t the problem; underlying social issues are. Who we are and what we do is inexorably linked to our family and community.
Housing First works because it focuses primarily on social recovery; it allows drug users to take on responsibility for their social lives. It gives them dignity by providing more opportunities to be involved in conventional life, community networks, and respectable social roles. Whether it is in a single home or a shared home, when the disenfranchised have a place to live, shower, cook and invite people over to socialize, it allows them to reintegrate in society.
Since social problems are the main cause of both substance abuse and homelessness, social solutions are needed.
Miriam Boeri received funding from the National Institutes of Health for previous research. She is affiliated with the Association for Applied and Clinical Sociology.