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Misconceptions About Homelessness Put Patients, EDs at Risk

Of 1,210 patients with any drug or unhealthy alcohol use who were not homeless at their initial ED visit, nearly one in 10 entered a homeless shelter in the next 12 months.1 The percentage increased to 40% for ED patients with severe drug use problems. Once the researchers controlled for other factors (including histories of homelessness), the relationship between substance use and future homelessness was no longer statistically significant.

“There’s a common stereotype of a unidirectional path of substance use causing homelessness. This assumption leads to a lot of blaming people experiencing homelessness for their own condition,” says Kelly Doran, MD, MHS, director of the Health x Housing Lab at NYU Grossman School of Medicine.

Previous research suggests the biggest causes of homelessness are structural ones like lack of affordable housing.2 Doran and colleagues conducted ED patient survey questionnaires, then linked these to a New York City homeless shelter database. Obtaining these data allowed researchers to study the association of detailed patient characteristics (including substance use types and severity) with future homeless shelter entry. “On the whole, combining the results we found in our study with what we have seen in past studies, I would describe the relationship of homelessness and substance use as bidirectional,” Doran says.

The findings suggest substance use can be both a cause (in combination with factors like poverty and lack of affordable housing) and a consequence of homelessness. “People who experience homelessness as children are more likely to use drugs and alcohol later in life, and also to experience homelessness as an adult,” Doran says. “There are real health consequences from the state of homelessness.”

For ED providers, there are important implications. “We are seeing a lot of patients who are at risk for future homelessness. There may be ways we can intervene,” Doran offers.3

Doran and colleagues conducted a pilot study of screening ED patients for risk of future homelessness and providing a referral to community prevention services. They are compiling the results of this pilot.

Meanwhile, there has been much recent attention to substance use services in EDs, such as treatment referrals or starting patients on buprenorphine. “Those efforts are really important, but may not reach their full potential unless they concomitantly recognize and address patients’ significant housing needs,” Doran says.

It is hard to say definitively if EDs are seeing more homeless patients because data collection and reporting lag real-time conditions, according to Bisan A. Salhi, MD, PhD, associate professor in the department of emergency medicine at Emory University.

“However, we do know that the number of people living in emergency shelters, transitional housing programs, and on the street has increased,” Salhi says.4

This increase likely is to be reflected in ED visits. Salhi says a common misconception is that people experiencing homelessness primarily come to EDs for food or shelter. “Put another way, there is a tendency to think that people experiencing homelessness are ‘less sick’ than other patients. In fact, there is a plethora of evidence to the contrary,” Salhi says.

Patients experiencing homelessness record higher rates of injury, along with morbidity and mortality, and experience greater stigma when trying to access healthcare and attend to their needs.5

To improve care of this population, Salhi suggests EPs document a patient is “experiencing homelessness” or use a specific description of the patient’s housing status, such as “patient is staying at a motel” or “patient is couch-surfing with friends.” Engage these patients in care plans the same way they would any other patient. Ensure the patient understands this treatment plan, and can carry it out if discharged.

“If not, try to modify the treatment plan to make it more feasible and engage other resources available for assistance,” Salhi says. For example, EPs may choose to prescribe a more affordable medication to facilitate adherence.

At minimum, take patients’ complaints seriously. “Uncritically believing that patients experiencing homelessness are in the ED for inappropriate or nonmedical reasons greatly increases the likelihood of a missed diagnosis, delayed care, or poor outcome for these patients,” Salhi warns.

REFERENCES

  1. Yoo R, Krawczyk N, Johns E, et al. Association of substance use characteristics and future homelessness among emergency department patients with drug use or unhealthy alcohol use: Results from a linked data longitudinal cohort analysis. Subst Abus 2022;43:1100-1109.
  2. Ararso Y, Beharie NN, Scheidell JD, et al. The joint effect of childhood abuse and homelessness on substance use in adulthood. Subst Use Misuse 2021;56:660-667.
  3. Doran KM. Commentary: How can emergency departments help end homelessness? A challenge to social emergency medicine. Ann Emerg Med 2019;74:S41-S44.
  4. Henry M, de Sousa T, Roddy C, et al. The 2020 annual homelessness assessment report (AHAR) to Congress. Part 1: Point-in-time estimates of homelessness. January 2021.
  5. Salhi BA, White MH, Pitts SR, Wright DW. Homelessness and emergency medicine: A review of the literature. Acad Emerg Med 2018;25:577-593.