Long-Term Housing and Work Outcomes Among Treated Cocaine-Dependent

Homeless Persons Journal of Behavioral and Health Services Research. 2007: 34: 17-33.

Stefan G. Kertesz1 Ashley N. Mullins2 Dennis Wallace3 Joseph E. Schumacher1

Jesse B. Milby1

1 University of Alabama at Birmingham2 Wright Institute3 Rho Federal Systems, Inc

Support: NIDA K23-DA15487 & NIDA R01-DA089475

Kertesz, 2007

Background

• Addiction treatment a common point of entry for homeless– 17% received treatment in past yr1

• Treatment goals include housing

• Policy depends on outcomes data

• Comparisons of housing vs treatment-first interventions de-emphasize treatment

• Researchers risk “talking past” each another

Burt et al. NSHAPC. 1996

Kertesz, 2007

Research on Different Wavelengths

• Addiction treatment studies– “# days housed/working in last 60” may be

opaque1

• Housing studies– Housing First vs. standard CoC

comparison cannot assure fidelity to proven addiction treatment technologies.2

1. Milby et al. Drug and Alcohol Dependence. 1996; 43:39-472. Tsemberis. Am J Pub Health. 2004; 94: 651-6

Kertesz, 2007

Addiction Treatment System: Impaired

Survey of 175 US programs1

• 15% stopped offering treatment within 16 mos.• 29% reorganized under new agency• 53% of Directors <1 year tenure• 73% of Directors had < BA• Non-counselor professionals rare

– Comparing excellent housing programs to underfunded, low-fidelity treatment programs tells us less than we need to know

McLellan. J Subst Ab Treat. 2003; 25: 117-21

Kertesz, 2007

Specific Research Question

• What long-term housing and employment outcomes from a 6-month treatment proven to be effective for homeless persons with combined addiction & mental illness?1,2, 3, 4

1. Milby et al. Am J Pub Health. 2005. 95:1259-1265. 2. Milby et al. Drug Alc Depend. 2000. 60: 55-67 3. Milby et al. Drug Alc Depend. 1996; 43: 39-47. 4. Milby et al (In Press) J Subst Abuse Treat. 5. Schumacher et al. In Press. J Consult Clin Psychol (meta-analysis)

Kertesz, 2007

Methods

• Hypothesis: Stable Housing/Employment will be more common, at 1 yr, in trial arms known to be most effective in reducing substance use

• Approach: Comparison of 1-year housing and employment outcomes

– From a 6-month randomized controlled trial– Cocaine-dependent mentally ill homeless in

Birmingham1

– Stronger trial arms proven to reduce drug use

1. Milby. Am J Public Health. 2005; 95: 1259-65.

Kertesz, 2007

Abstinence-Contingent Housing

+ DT (N=63)

Nonabstinence-Contingent Housing

x + DT (N=66)

No Housing Provided

+ DT (N=66)

HomelessCocaine+ Mental Illness

Treatment-SeekersN=195

Months 7-12Months 0-6

Outcomes at 12 months

N=138 (71%)

% Stably Housed% Stably Employed

UnavailableN=57 (29%)

Trial Design

Kertesz, 2007

• With negative urine receive: – continued housing– work-training with incentives– weekly Wal-Mart shopping – work training refurbish buildings for homeless via Bad Boy Builders

Inc

• With positive urine lose:– apartment (transport to secure shelter, with van ride for daily

treatment)

• But continue:– Work training, day treatment, incentives for goal attainment,

supervised shopping trip

• With 2 consecutive negative urines:– Return to apartment

Abstinence-Contingent Housing (6 Month Treatment Program)

Kertesz, 2007

Outcome Measures at 12 months

> 45 days in last 60:

Stable Housing Own Apt/House, parent/family, SRO, long-term sober residence, boarding houseNot: shelter, hospital, halfway house, treatment facility

Stable Employment

Full-time, regular part-time, student, military Not: day labor

Participant Characteristics

Housing Contingent

on Abstinence

Housing, not

Requiring Abstinence

No Housing Provided

N N=45 N=54 N=39

Age 37 (32-43) 42 (32-43) 36 (32-43)

African-American 91% 96% 97%

Female 29% 26% 26%

Axis I Diagnosis 82% 83% 72%

Axis II Diagnosis 51% 61% 49%

Kertesz, 2007

Proportion of Weekly Urines “Clean” During Months 3-6 of Treatment

Milby et al. Am J Public Health. 2005; 95: 1259-65.

p=0.0001 (3-group comparison)

Kertesz, 2007

Housing & Employment Outcomes at 12 Months Among 138 Cocaine-Dependent Homeless Who

Entered Intensive Behavioral Treatment

Kertesz et al. J Behavioral Health Services & Research. January 2007

Kertesz, 2007

Glass 43% full or 57% empty?

• More efficacious treatment-->better housing & work outcomes– Program Housing helped 2 trial arms– ACH didn’t want NACH clients around

• But we remain concerned…

Kertesz, 2007

Why did success elude the majority?

• Maybe treatment shouldn’t end1

• Work income < Rent– In a later trial, <1/2 of work was subject to

unemployment insurance

• Entry to Shelter Plus Care required:– 3 mos perfect abstinence (22% attained)– Now2: 6 mos.– Unattainable standards for housing entry

1. McLellan et al. JAMA. 2000. 284:1689-95 2. Local waiver for one Housing First program for the severely mentally ill

Kertesz, 2007

Conclusions

• Evidence-based addiction treatment improves housing & employment

• Return to permanent housing/employment can be elusive– Not highly desirable employees or tenants– Subsidized housing may impose

unattainable standards locally– Paychecks may be insufficient

Kertesz, 2007

Implications

• Treatment for dually-diagnosed homeless requires sufficient investment

• Perfect abstinence an uncommon treatment outcome

• Low service support for subsidized housing promotes “creaming”

• Persons going through Housing First or Treatment First will need service supports for stable housing

Kertesz, 2007

Thank-you

Kertesz, 2007

A. Long-TermHomeless

At High riskMed+Mental+

AddictionOften have conflictsIn highly demanding

Group-basedRehab

B. Short & Long-term

Moderate Risk

Addiction & nonsevere mental illness

Higher social resources and/or functional

potential

Chronically Homeless

Journal of Behavioral and Health Services Research. 2007: 34: 17-33.