Addiction Among the Homeless Population

The opioid epidemic may be decreasing, finally, but substance use disorder is still on the rise. The economy is on the rise, also, but homelessness is still a growing problem. There is also significant overlap between these two groups.

Not that homelessness is usually a long-term condition. For some, it lasts only a day or two until they find a place to stay (family, friends, a shelter). Others may stay in a shelter for less than a month and then are never homeless again.

Where Do the Homeless Sleep?

According to The U.S. Department of Housing and Urban Development report 2020, 580,466 people – about 18 of every 10,000 people in the United States – experienced homelessness across the United States. Among them, 61% were staying in sheltered locations, and nearly 39% were unsheltered. Unsheltered homeless persons live on the streets or live-in tents, cars, or abandoned buildings. Sheltered homeless persons stay in an emergency or transitional housing temporarily. Sheltered homeless persons are still considered homeless because they lack their own stable, permanent housing.

Homelessness, Mental Disorders, and Addiction

Some of the homeless have a mental health disorder, a substance use disorder, or both.

Mental health disorders include depression, anxiety, trauma, and bipolar disorders. Substance use disorder—alcohol use disorder, opioid use disorder—is a chronic disease as well as a mental health disorder, and is characterized by finding and using said substances ahead of all other priorities, including shelter.

Homeless adults’ most common substance of abuse is alcohol, while homeless youth are more likely to abuse drugs, including marijuana and cocaine.

Add in other mental health issues, and the picture grows murkier still. In 1988, U.S. President Ronald Reagan said that many of the homeless population chose to be the unsheltered homeless—i.e, live on the streets rather than in shelters—because they were mentally ill.

The argument goes that the American Civil Liberties Union made it illegal to involuntarily commit someone who wasn’t an imminent threat to themselves or others, which led to more people with mental health disorders living on the street.

While there is some truth to that, it’s also true that U.S. states cut funding to and/or closed their mental hospitals and haven’t always been aggressive in opening new homeless shelters or promoting existing ones.

What shelters there are sometimes do not have enough beds to meet demand. Shelters are not usually long-term homes. Many are only a place to sleep and get a meal. The homeless clients still have to wander the streets during the day and hope there is room in the shelter later.

There are other reasons besides mental illness that some might prefer to live on the streets rather than in some homeless shelters, including:

• Violence
• Theft
• Drugs
• Disease
• Unsanitary conditions (dirt, bed bugs, lice, odors)
• Crowds
• Inadequate heat or air conditioning

While five times as many sheltered homeless individuals do have a severe mental illness compared to U.S. adults in general, that’s still just 25%. According to cities surveyed, greater dangers are the lack of affordable housing and gainful employment.

What Causes Homelessness?

If mental health disorders such as substance use disorder aren’t the only or main cause, what causes homelessness? Lack of affordable housing was the top reason cited in a 2014 survey of 25 cities—for both unaccompanied individuals and families with children—followed by unemployment and poverty. Substance use disorder was tied for fourth place (along with mental illness and lack of needed services) for individuals and sixth for families.

According to Santa Clara County’s Homeless Census, 68% just couldn’t afford rent. Especially in high-rent areas, finding affordable housing is difficult. This is not just a problem for out-of-work singles with a mental disorder and/or substance use disorder.

As many as 22%  of homeless single adults and 25% of adults in homeless families are employed—approximately half of the homeless population shifts between full-time and part-time work.

Part of the problem is that minimum wage jobs in all 50 states don’t pay enough to rent even a one-bedroom apartment unless the individuals work a minimum of 69 hours a week. In some states, it would require at least 174 hours per week. And that’s at the federal government’s Fair Market Rent (FMR) standard.

Women, Homelessness, and Addiction

Men are more likely to be homeless than women. Only one out of four chronically homeless adults is a woman. Still, homeless women are much more vulnerable than homeless men.

While it is difficult to determine the rate of addiction among homeless populations (sources vary), homelessness does seem to lead to higher use of alcohol and drugs than people with low incomes but who have shelter. The rates are slightly higher for men than women.

Nearly half of homeless women in Los Angeles use drugs, and almost a third binge drink (consume large amounts of alcohol in a short amount of time). That’s about three times and double, respectively, the rates for low-income women with a home.

Based on multiple studies, the most common drugs of abuse among homeless women are alcohol, marijuana, and cocaine in their crack form.

The percentage of homeless women ages 25 to 44 who died from a drug overdose is 9.6-fold higher than U.S. women of the same age in general.

Young Adults, Homelessness, and Addiction

As bad as homelessness, even temporary homelessness, seems, underage homelessness is more disturbing because these youths are much more vulnerable. They are not legally able to do many things adults can do. They may not even have a high school diploma or other education, making it far harder to lift themselves out of homelessness.

At least 3% of people ages 13 to 17 without a parent or guardian are homeless for part of the year.

It’s not surprising that drug abuse is more common among homeless youth. More than one in four has a substance use disorder (SUD), though some estimates say the number is as high as 81%. More than two-thirds of these young people have a separate mental health issue.

Common drugs of abuse include methamphetamine (meth) to stay awake and alert, as well as alcohol and heroin to numb their fears and cope with homelessness.

Other risk factors include:

• Conflicts at home
• Problems at school
• Time spent in foster care and their age when first entering
• A history of running away
• Sexual activity
• Pregnancy
• Sexual orientation

To survive on the streets, homeless youth may be forced or seduced into criminal activities such as theft, selling (and using) drugs, and sex work. This increases their risks of entering the juvenile or adult justice system, overdosing, experiencing violence up to and including murder, and contracting and spreading AIDS and other sexually transmitted diseases.

LGBTQ Community, Homelessness, and Addiction

If being young, mentally ill, addicted, and homeless is bad, being LGBTQ—lesbian, gay, bisexual, transgender, and/or queer or questioning—is even worse. LGBTQ youth are twice as likely to be homeless.

Polling company Gallup estimates that as many as 40% of homeless youth identify as LGBTQ, though only 7% of youth are LGBTQ (as opposed to 4.5% of the overall population).

LGBTQ individuals, in general, are twice as likely to have used any illicit drug in the past year, more likely to develop a substance use disorder (SUD) or binge drink, and (at least among those seeking alcohol use disorder rehab) to have started drinking at a younger age. They are also more likely to have a co-occurring mental health issue.

Many LGBTQ youths became homeless when they ran away because:

• Their family rejected them due to their sexual orientation or gender identity (46%)
• Their parents forced them out (43%)
• They faced physical, emotional, or sexual abuse at home (32%)

On the street, they may have been forced into exchanging sex for food, clothing, or shelter. They are also at greater risk of physical violence and death at the hands of intolerant strangers or their families.

Even in shelters, homeless LGBTQ youths are at greater risk because there is a lack of understanding of what it means. There are sometimes more myths and misinformation than facts.

Homeless shelters often segregate youth on the basis of the gender assigned them at birth, from beds to bathrooms, which can lead to physical violence and/or rape.

Without proper medical care, homeless LGBTQ youths may resort to black market drugs of unknown origin to attempt to make their bodies more closely resemble their gender identity.

Adult LGBTQ individuals aren’t treated much better at shelters. More than half of transgender adults (55%) were harassed by other residents or staff if they tried to enter a shelter, more than a quarter (29%) were turned away, and more than a fifth (22%) were sexually assaulted.

No wonder that some of the nonmentally ill, substance-abusing, and homeless population resist entering a shelter.

The relationships among homelessness, mental illness, and substance use disorder are complicated already, and there are other factors involved. From 2012 to 2018, as the economy improved and the Great Recession receded, the overall homelessness rate in the United States declined, but it increased in the most prosperous regions.

Solutions require not just a dual diagnosis but multipronged strategies. The strategies include wage and housing reform, empathy, increased availability of psychological counseling and treatment, and online access to the documents and resources to make homelessness a short-term problem, not a long-term condition.