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The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder.

ABSTRACT: BACKGROUND:Substance use is disproportionately high among people who are homeless or vulnerably housed. We performed a systematic overview of reviews examining the effects of selected harm reduction and pharmacological interventions on the health and social well-being of people who use substances, with a focus on homeless populations. METHODS AND FINDINGS:We searched MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute EBP, Cochrane Database of Systematic Reviews and DARE for systematic reviews from inception to August 2019. We conducted a grey literature search and hand searched reference lists. We selected reviews that synthesized evidence on supervised consumption facilities, managed alcohol programs and pharmacological interventions for opioid use disorders. We abstracted data specific to homeless or vulnerably housed populations. We assessed certainty of the evidence using the GRADE approach. Our search identified 483 citations and 30 systematic reviews met all inclusion criteria, capturing the results from 442 primary studies. This included three reviews on supervised consumption facilities, 24 on pharmacological interventions, and three on managed alcohol programs. Supervised consumption facilities decreased lethal overdoses and other high risk behaviours without any significant harm, and improved access to care. Pharmaceutical interventions reduced mortality, morbidity, and substance use, but the impact on retention in treatment, mental illness and access to care was variable. Managed alcohol programs reduced or stabilized alcohol consumption. Few studies on managed alcohol programs reported deaths. CONCLUSIONS:Substance use is a common chronic condition impacting homeless populations. Supervised consumption facilities reduce overdose and improve access to care, while pharmacological interventions may play a role in reducing harms and addressing other morbidity. High quality evidence on managed alcohol programs is limited.

SUBMITTER: Magwood O

PROVIDER: S-EPMC6964917 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BACKGROUND:Individuals who are homeless or vulnerably housed are at an increased risk for mental illness, other morbidities and premature death. Standard case management interventions as well as more intensive models with practitioner support, such as assertive community treatment, critical time interventions, and intensive case management, may improve healthcare navigation and outcomes. However, the definitions of these models as well as the fidelity and adaptations in real world interventions are highly variable. We conducted a systematic review to examine the effectiveness and cost-effectiveness of case management interventions on health and social outcomes for homeless populations. METHODS AND FINDINGS:We searched Medline, Embase and 7 other electronic databases for trials on case management or care coordination, from the inception of these databases to July 2019. We sought outcomes on housing stability, mental health, quality of life, substance use, hospitalization, income and employment, and cost-effectiveness. We calculated pooled random effects estimates and assessed the certainty of the evidence using the GRADE approach. Our search identified 13,811 citations; and 56 primary studies met our full inclusion criteria. Standard case management had both limited and short-term effects on substance use and housing outcomes and showed potential to increase hostility and depression. Intensive case management substantially reduced the number of days spent homeless (SMD -0.22 95% CI -0.40 to -0.03), as well as substance and alcohol use. Critical time interventions and assertive community treatment were found to have a protective effect in terms of rehospitalizations and a promising effect on housing stability. Assertive community treatment was found to be cost-effective compared to standard case management. CONCLUSIONS:Case management approaches were found to improve some if not all of the health and social outcomes that were examined in this study. The important factors were likely delivery intensity, the number and type of caseloads, hospital versus community programs and varying levels of participant needs. More research is needed to fully understand how to continue to obtain the increased benefits inherent in intensive case management, even in community settings where feasibility considerations lead to larger caseloads and less-intensive follow-up.

Project description:BackgroundPeople experiencing homelessness are often marginalized and are known to face barriers to accessing acceptable and respectful healthcare services. This study examines the experience of accessing hospital-based services of persons experiencing homelessness or vulnerable housing in southeastern Ontario and considers the potential of Equity-Oriented Health Care (EOHC) as an approach to improving care.MethodsFocus groups and in-depth interviews with people with lived experience of homelessness (n=31), as well as in-depth interviews of health and social service provider key informants (n=10) were combined with qualitative data from a survey of health and social service providers (n=136). Interview transcripts and written survey responses were analyzed using directed content analysis to examine experiences of people with lived experience of homelessness within the healthcare system.ResultsHealthcare services were experienced as stigmatizing and shaming particularly for patients with concurrent substance use. These negative experiences could lead to avoidance or abandonment of care. Despite supposed universality, participants felt that the healthcare system was not accountable to them or to other equity-seeking populations. Participants identified a system that was inflexible, designed for a perceived middle-class population, and that failed to take into account the needs and realities of equity-seeking groups. Finally, participants did identify positive healthcare interactions, highlighting the importance of care delivered with dignity, trust, and compassion.ConclusionsThe experiences of healthcare services among the homeless and vulnerably housed do not meet the standards of universally accessible patient-centered care. EOHC could provide a framework for changes to the healthcare system, creating a system that is more trauma-informed, equity-enhancing, and accessible to people experiencing homelessness, thus limiting identified barriers and negative experiences of care.

Project description:BACKGROUND:Homelessness is one of the most disabling and precarious living conditions. The objective of this Delphi consensus study was to identify priority needs and at-risk population subgroups among homeless and vulnerably housed people to guide the development of a more responsive and person-centred clinical practice guideline. METHODS:We used a literature review and expert working group to produce an initial list of needs and at-risk subgroups of homeless and vulnerably housed populations. We then followed a modified Delphi consensus method, asking expert health professionals, using electronic surveys, and persons with lived experience of homelessness, using oral surveys, to prioritize needs and at-risk sub-populations across Canada. Criteria for ranking included potential for impact, extent of inequities and burden of illness. We set ratings of ? 60% to determine consensus over three rounds of surveys. FINDINGS:Eighty four health professionals and 76 persons with lived experience of homelessness participated from across Canada, achieving an overall 73% response rate. The participants identified priority needs including mental health and addiction care, facilitating access to permanent housing, facilitating access to income support and case management/care coordination. Participants also ranked specific homeless sub-populations in need of additional research including: Indigenous Peoples (First Nations, Métis, and Inuit); youth, women and families; people with acquired brain injury, intellectual or physical disabilities; and refugees and other migrants. INTERPRETATION:The inclusion of the perspectives of both expert health professionals and people with lived experience of homelessness provided validity in identifying real-world needs to guide systematic reviews in four key areas according to priority needs, as well as launch a number of working groups to explore how to adapt interventions for specific at-risk populations, to create evidence-based guidelines.

Project description:BackgroundDiagnosed PTSD rates in people who are homeless are more than double that of the general population, ranging between 21 and 53%. Complex PTSD (cPTSD) also appears to be more common than PTSD. One treatment option is Narrative Exposure Therapy (NET), a brief trauma-focused psychotherapy which attempts to place trauma within a narrative of the person's life. Our primary aim was to assess the feasibility and acceptability of recruiting people to a randomized controlled trial (RCT) of NET alone compared to NET augmented by a genealogical assessment. We hypothesized that incorporating a genealogical assessment may be more effective than NET alone in a population with predominately complex PTSD.MethodsThis pilot RCT enrolled participants who were 18 years of age or older, currently homeless or vulnerably housed, and with active symptoms of PTSD. Participants were randomized to NET alone or NET plus a genealogical assessment. Rates of referral, consent, and retention were examined as part of feasibility. Demographic and clinical data were collected at baseline. Symptoms of PTSD, drug use, and housing status were re-assessed at follow-up visits. We conducted a thematic analysis of qualitative interviews of service providers involved in the study which explored barriers and facilitators of study participation.ResultsTwenty-two potential participants were referred to the study, with 15 consenting to participate. Of these, one was a screen failure and 14 were randomized equally to the treatment arms. One randomized participant was withdrawn for safety. Attrition occurred primarily prior to starting therapy. Once therapy began, retention was high with 80% of participants completing all six sessions. Seven participants completed all follow-up sessions. Service providers identified a clear need for the treatment and emphasized the importance of trauma-informed care, a desire to know more about NET, and more communication about the process of referral.ConclusionRecruiting participants who were vulnerably housed to an RCT of a trauma-based therapy was possible. Once therapy had started, participants were likely to stay engaged. We will incorporate the results of this trial into a conceptual model which we will test in a factorial study as part of the optimization phase of MOST.Trial registrationClinicalTrials.gov NCT03781297 . Registered: December 19, 2018.

Project description:IntroductionFoot problems are common among homeless persons, but are often overlooked. The objectives of this systematic review are to summarize what is known about foot conditions and associated interventions among homeless persons.MethodsA literature search was conducted on MEDLINE (1966-2016), EMBASE (1947-2016), and CINAHL (1982-2016) and complemented by manual searches of reference lists. Articles that described foot conditions in homeless persons or associated interventions were included. Data were independently extracted on: general study characteristics; participants; foot assessment methods; foot conditions and associated interventions; study findings; quality score assessed using the Downs and Black checklist.ResultsOf 333 articles screened, 17 articles met criteria and were included in the study. Prevalence of any foot problem ranged from 9% to 65% across study populations. Common foot-related concerns were corns and calluses, nail pathologies, and infections. Foot pathologies related to chronic diseases such as diabetes were identified. Compared to housed individuals across studies, homeless individuals were more likely to have foot problems including tinea pedis, foot pain, functional limitations with walking, and improperly-fitting shoes.DiscussionFoot conditions were highly prevalent among homeless individuals with up to two thirds reporting a foot health concern, approximately one quarter of individuals visiting a health professional, and one fifth of individuals requiring further follow-up due to the severity of their condition. Homeless individuals often had inadequate foot hygiene practices and improperly-fitting shoes. These findings have service provision and public health implications, highlighting the need for evidence-based interventions to improve foot health in this population. An effective interventional approach could include optimization of foot hygiene and footwear, provision of comprehensive medical treatment, and addressing social factors that lead to increased risk of foot problems. Targeted efforts to screen for and treat foot problems could result in improved health and social outcomes for homeless individuals.

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The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder.

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