‘Dignity first’: improving the lives of homeless people who drink and take drugs
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‘Dignity first’: improving the lives of homeless people who drink and take drugs

One of our hot topics offering background and analysis on important issues which sometimes generate heated debate. Putting people with experiences of homelessness and substance use problems at the centre of social policy, this hot topic asks what solutions would look like if they prioritised saving lives and improving lives.

Focusing on people with overlapping experiences of homelessness and substance use, this hot topic examines what social policies would look like if they prioritised saving lives and improving lives. It brings together evidence about needs, gaps in services, and ‘what works’, as well as commentary about some of the myths and misconceptions that have fostered policies which do more harm than good.

The hot topic questions the public disorder lens through which homelessness and substance use problems tend to be viewed, and challenges the lack of public responsibility for the conditions that lead to these problems. It also brings to the fore a key debate in the field of substance use: the validity of harm reduction not just as a mechanism to engage people who use drugs with treatment, but as a legitimate goal in itself.

Rough sleeping is just the ‘tip of the iceberg’

Though homelessness is traditionally associated with rough sleeping, someone who has a roof over their head can still be homeless according to today’s understanding. The term now covers a spectrum of living situations notable by the absence of safety, security, and stability, including:
• people residing in temporary accommodation: night/winter shelters, hostels, B&Bs, women’s refuges, and private/social housing;
• ‘statutory homeless’: people who local authorities have a legal duty to secure a home for;
• people sleeping rough: people who sleep (or bed down) in the open air, or in places not designed for human occupancy;
• ‘hidden homeless’: people dealing with their situation informally (ie, staying with family and friends, ‘couch-surfing’ or ‘squatting’).

Quantifying the various types of homelessness is a complicated task: the ‘best estimates’ often come from different sources and using different methods; some groups of people are more likely to be missed by counts than others, and therefore may be under-represented in estimates of homelessness; and people often cycle in and out of homelessness, and experience more than one official type. However, the figures do consistently suggest that the most visible form of homelessness, rough sleeping, is just the ‘tip of the iceberg’. Outnumbering people sleeping rough are people living in ‘temporary accommodation’ – an arguably misleading term given that some people will find themselves living in temporary accommodation indefinitely – and greater still are the numbers of people thought to fall under the umbrella of the hidden homeless, most of whom will have also have slept rough at some time. The problem doesn’t end there – beyond the currently homeless are also millions of people on the brink.


Rough sleeping is just the ‘tip of the iceberg’: a representation of different types of homelessness in England from UK charity Shelter

At present there is no mechanism for counting every single person who sleeps rough in the United Kingdom, and there are a range of factors that influence the number of people sleeping rough on any given night and the chances that they will be spotted (including the weather and availability of alternatives such as night shelters). In England, the Ministry of Housing, Communities and Local Government endorses local authorities arriving at a snapshot of the “number of people sleeping rough in their area on a typical night” using one of three approaches:

  1. count-based estimate of visible rough sleeping: the number of people seen sleeping rough in the local authority area on a single date chosen by the local authority between 1st October and 30th November;
  2. evidence-based estimate: an evidence-based assessment by partners, leading to a single figure that represents the number of people thought to be sleeping rough in the local authority area on a typical night, which may include people hidden from view;
  3. evidence-based estimate including a spotlight count: an evidence-based assessment by partners along with a street count of people visibly sleeping rough.

The same method has been in place since 2010 providing enough consistency of ‘counting’ to examine the trends over the last almost decade. In autumn 2018, there were an estimated 4,677 people sleeping rough in England (of whom 1,283 were in London) – a rise of 165% since 2010 when there were 1,768 people sleeping rough in England (415 in London). Compare these figures to those derived from an alternative method for counting rough sleeping in the London area only, and it would seem that the UK Government estimate is on the conservative side, underestimating the scale of the problem. According to the Combined Homelessness and Information Network (CHAIN) database – commissioned and funded by the Mayor of London and managed by UK homelessness charity St Mungo’s – there were a recorded 3,289 people sleeping rough on at least one night over a three-month period (October–December) in 2018, meaning that over half of people vulnerable to rough sleeping over a similar time period were in effect missed by the official counts of rough sleeping.

On 31 March 2018, the number of households in England in temporary accommodation was 80,720, most of which (61,610) included dependent children and/or a pregnant woman. Between April and June 2018, 123,630 young people in England were residing in temporary accommodation, marking a 70% increase from 2010 and a rise of nearly a quarter in the previous three years. In what has been hauntingly dubbed “The housing crisis generation”, it is estimated that 1 child in every 103 in Great Britain is homeless (compared to England where the rate is 1 in 96; Scotland, 1 in 156; and Wales, 1 in 41), with the highest rate in England seen in London (1 in 23). Per school this makes for five homeless children in England, with 28 for every school in London.

Shelter, a leading charity fighting bad housing and homelessness, also estimates that eight million people are ‘one pay cheque away’ from being unable to pay for their home. Based on a survey of over 2,000 adults, families with children were found to be in the most precarious situation of all with 43% unable to pay for their home for more than a month, and nearly a quarter (23%) unable to meet their payments at all. From their vantage point the charity was seeing missed opportunities for preventing homeless, and new reasons for people being exposed to homelessness. Shelter’s Chief Executive, Campbell Robb, warned:

“These figures paint an alarming picture of a nation where the buffer between having a home and potentially becoming homeless is a single pay check. The depth of the financial pressure and insecurity felt by people across the country means that millions are living on the edge of a crisis, only secure in their homes for a matter of weeks. At the same time, support for people who have lost their homes is being stripped away – it’s easy to see why every fifteen minutes, another family in England finds themselves homeless.”

Like warnings before it, this representation of homelessness struck as an attempt to close the ‘empathy gap’ by normalising the conditions that lead to homelessness. However, in doing so it arguably obscured one of the more important facts of homelessness – that while homelessness can happen to anyone, it doesn’t just happen to anyone; there is a “profoundly unequal set of risks across the general population”.

‘A profoundly unequal set of risks’

Refuting the notion of us all being one or two steps away from homelessness, a 2018 study found that the odds of experiencing homelessness are systematically structured around a set of identifiable individual and structural factors, most of which are outside the control of those directly affected, including the lack of affordable housing, decline of the social housing sector as a proportion of all housing, unemployment, and poverty (especially childhood poverty). By family type, the greatest proportion of people in persistent poverty (ie, an income level below minimum living standards for two of the three preceding years) are single parents – totalling 24% of all those in persistent poverty between 2013 and 2017, compared with 11% for a couple with children, 9% for a single female without children, 10% for a single male without children, and 4% for a couple without children.

Factors commonly associated with homelessness

Individual factors: mental health problems, substance use problems, leaving prison, being discharged from the armed forces, bereavement, relationship breakdown, violence, harassment or abuse, and domestic abuse, financial issues.

Structural factors: lack of affordable housing, welfare reforms, poverty, and unemployment.

One of the biggest overall causes of homelessness is the loss of a private tenancy. In 2015, this was the ‘No. 1’ cause with 17,190 (30%) households in England recognised as being homeless by their local council after an eviction from a privately-rented home. According to the 2019 figures, this reason has now been overtaken by the 18,150 (26%) households homeless due to friends or family no longer willing or able to accommodate, compared with the termination of a tenancy for 14,700 (21%) households.

While men and women are reported to be at equal risk of homelessness, the patterns around how they become homeless, and the harms they experience while homeless look quite different.

Compared to men, women are considerably more likely to end up homeless as a result of domestic abuse. Even when it when it is not a direct cause, domestic abuse is near-universal among women who become homeless. For women living in abusive relationships or within an abusive family, it has been likened to feeling ‘homeless at home’. In such circumstances, temporary accommodation such as women’s refuges might be the stepping stone to independent living, although understandably these shelters present their own challenges, such as the lack of privacy, loss of personal and parental freedom, and diminished self-respect, which distinguishes them from longer-term/sustainable solutions to homelessness.

According to the figures, men are at far greater risk of sleeping rough than women, and indeed are more likely to be exposed to rough sleeping for longer periods of time, while women tend to be over-represented among those in temporary accommodation and those managing their situation informally. Though perhaps preferable to rough sleeping, accommodation in hostels and nightshelters is not an ideal long-term solution. These facilities seldom have anywhere to cook and often require residents to vacate the property during the day – a constant reminder of no having anywhere to call home. Furthermore, even ‘off the streets’, women remain particularly vulnerable to sexual violence and exploitation, including ‘survival sex’ when faced with immediate survival needs such as securing shelter, finding financial resources, and ensuring safety for themselves and their children.

There is anecdotal evidence that women are being undercounted in rough sleeping numbers – for example, where women are sleeping rough, they are taking efforts to hide themselves (eg, hiding in people’s back gardens and concealing their gender). However, it also makes sense that women would sleep rough at a lower rate than men. Women are more likely to draw on (and exhaust) informal resources to manage their homelessness before seeking help, and may also be shielded from rough sleeping when they have their children with them because welfare, social services, health and social housing systems are designed to protect young people.

Men are disproportionately affected by homelessness in other ways – none more striking than when we look at figures of deaths among the homeless. For example, of the 597 homeless people who died in England and Wales in 2017, 84% were men. The figures also show a clear inequality in life expectancy between homeless people and the general population. In 2011, UK homelessness charity Crisis found that homeless people were dying on average 30 years before the general population (48 for men and 43 for women, compared to 74 and 80 respectively), and a third of deaths were related to drink and drugs.

As recent assessments would indicate, the situation has been getting worse rather than better. Figures from the Office for National Statistics revealed that there was a 24% increase in homeless deaths between 2013 and 2017 in England and Wales (from 482 to 597). The average age was 44 years old (44 years for men, 42 years for women), and more than half died from causes related to drugs (32%), alcohol (10%) or suicide (13%) – much higher than the 3% of deaths attributable to drugs, alcohol, or suicide in the general population over the same period.

Ben Humberstone, head of health analysis at the Office of National Statistics, said:

“What’s striking about these figures is how different they are to the general population – 55% of the deaths of homeless people are related to drugs, suicide or alcohol, also known as the diseases of despair, compared to just 3% of deaths from these causes among the general population.”

An analysis by St Mungo’s showed that the number of drug-related deaths among people sleeping rough or in emergency accommodation increased substantially between 2013 and 2018, from 125 to 294 (a 135% increase). The biggest rise across that time period was between 2017 and 2018, when the number of deaths jumped 55% from 190 to 294. These deaths were overwhelmingly linked to the use of opiates (eg, heroin, morphine or fentanyl), often combined with alcohol and other substances.

Confirming that drug deaths are disproportionately the province of the poor and isolated, in England in 2013 reports from coroners to a national surveillance programme identified half the deceased as unemployed and half as living alone or with no settled home. Of the 1,115 drug-related deaths that occurred in England in 2013 meeting the classification of ‘drug misuse’ deaths, 4% of people died in public places such as parks or public facilities. Public Health England’s expert group has agreed that drug-related deaths are unduly seen among divorced people and single men, again identifying social isolation as among the factors aggravating risk.

The prominent role of drugs and alcohol in the deaths of homeless people beg the question of why substance use is having such a severe impact on this population – how are homelessness and substance use problems related, what are the specific harms, and how harms can be reduced in order to save lives?

The overlap between substance use problems and homelessness

Problems with drugs and alcohol are among the individual factors or personal circumstances (distinguishable here from environmental, social, or structural factors) commonly associated with homelessness (1 2). In some cases, they may be the ‘triggering event’ for homelessness, for example, the reason given for someone losing their tenancy or being asked to leave home. However, more generally, substance use problems seem to increase a person’s vulnerability to homelessness.

Especially when coexisting, homelessness and substance use problems evoke a state of extreme hardship. They also, according to research, reflect a status of deep social exclusion. ‘Multiple exclusion homelessness’ is the term given to concurrent experiences of different types of exclusion, deprivation, and suffering, for example, homelessness along with substance use problems, a history of living in institutional care (eg, prison, local authority care, mental health hospitals, and wards), and participation in ‘street culture’ activities (eg, begging, street drinking, ‘survival’ shoplifting, and sex work).

Aiming to deepen understanding of the causation of “one of the most visible, and disruptive, dimensions of severe and multiple disadvantage in the UK and other developed economies”, a study examined pathways into multiple exclusion homelessness among people in seven UK cities (Belfast, Birmingham, Bristol, Cardiff, Glasgow, London, and Leeds), finding that:
• substance use and mental health problems tended to arise early in people’s pathways – consistent with theories that childhood trauma can undermine coping mechanisms in young adulthood, with potentially long-term consequences for their health, wellbeing, and social functioning;
• homelessness, ‘street lifestyles’, and adverse life events typically occur later in these pathways – strongly implying that these experiences are more likely to be consequences of marginalisation rather than the origins or causes.

To acknowledge the deep social exclusion of homeless people with substance use problems is to also acknowledge depleted recovery capital – the “internal and external assets required to initiate and sustain long-term recovery”. Given the propensity for the wider public to overestimate personal responsibility for hardship, and underestimate the weight of wider environmental, social, and structural factors, cultivating an understanding of deep social exclusion would seem vital.

How then have social policies to date framed the double jeopardy of homelessness and substance use problems? Have they responded with urgency to the suffering and deprivation of multiply excluded homeless people, and strived to get to the root of why extreme hardship is often accompanied by or precipitated by deep exclusion from mainstream society? Or, have they focused on the deficits of multiply excluded homeless people and held them responsible for their deviation from mainstream society? At the sharp end of policies we can see approaches that aim to tackle the antisocial nature of ‘street lifestyles’ (such as rough sleeping, street drinking, public injecting) – generated by concern, often excessively so, about how other people are impacted by the manifestation of these problems in the public sphere, and an expectation that there be material consequences for breaching social norms and disturbing the peace of the majority.

Antisocial ‘street lifestyles’

Despite the risks inherent in rough sleeping, street drinking, and public injecting, they are frequently painted as a problem of antisocial behaviour for other people – exposing the general public to practices that are usually otherwise confined to socially-sanctioned spaces (such as pubs, bars, restaurants, and the home) or hidden from sight altogether because of the stigma and shame attached to them.

In practice, the range of deterrents used against people who are homeless and/or frequently spending time on the streets or other public spaces include:
• Criminal measures: Public Space Protection Orders under the Anti-Social Behaviour, Crime and Policing Act 2014, and the pre-Victorian Vagrancy Act.
• Civil measures: So-called ‘defensive architecture’ (street furniture and the urban environment may include features such as spikes, curved or segregated benches, and gated doorways, to deter rough sleeping), ‘wetting down’ (spraying and hosing down doorways/alleyways with water or cleaning products to stop rough sleepers using the space), noise pollution (sounds, such as loud music, are projected through speakers to deter rough sleepers), moving-on (security guards/enforcement agencies tell rough sleepers to move out of an area), and diverted giving schemes (local authority sanctioned schemes that promote and advertise in begging hotspots asking members of the public to reconsider giving money to beggars and give to local charities instead).

The addition of specific antisocial behaviour provisions to the law via the Anti-Social Behaviour, Crime and Policing Act 2014 gave police the powers to address behaviour that “has caused, or is likely to cause, harassment, alarm or distress to any person”, thereby responding to the impact of antisocial behaviour, as opposed to considering whether it has met an objective threshold of harassment, alarm, or distress. At least on paper the Act provided a greater level of protection for vulnerable people who are: (a) at greater risk of harm as a result of antisocial behaviour; and (b) more likely to be targeted in the first place because of their vulnerabilities. However, in practice the Act created room for the reverse to happen: anyone could claim to be harassed, alarmed, distressed, or annoyed by vulnerable people, including by people exhibiting symptoms of drug/alcohol dependence, mental illness, and learning disabilities or people sleeping rough.

The antisocial behaviour skew on people engaged in rough sleeping, street drinking, public injecting, begging, and sex work reflects a trend of prioritising the expressed or expected needs of the majority, at the expense of marginalised populations – criminalising their behaviour, further ostracising them, and ignoring their own vulnerability to harm in public spaces.

In the UK, public angst about street drinking informed the proliferation of so-called ‘alcohol-free zones’, which prevented people from drinking in public if police believed their drinking was causing a problem. A survey before the first street drinking ban was enacted in Coventry in 1988 found that, although in the past year just 9% of respondents had been insulted or bothered by strangers who had been drinking, up to 60% feared such incidents, and over 60% said they avoided areas where street drinkers congregated. Two-thirds felt “unruly groups of young people” were a problem and over half felt the same of people drinking in public. In Lancaster, community members viewed street drinking as ‘disrupting the social order’, and as a ‘morally offensive activity’.

A 2012 review examined evidence for alcohol-free zones and found that, on the whole, the widespread implementation of street drinking laws in urban areas had not been matched or preceded by research on their effectiveness. What evidence there was indicated that while alcohol-free zones played a role in reassuring communities, they often resulted in displacing the problems and the people, were not associated with reduced congregations of drinkers or reduced alcohol-related crime or harm, were not understood and adhered to by the community, and furthermore tended to come at the expense of further marginalising street drinkers, which research suggests at least half of whom will be homeless.

Allocating resources towards policing alcohol-free zones and essentially criminalising street drinking has different and more severe implications for homeless people: firstly, it precludes a sensitive response to homeless people’s mental health and substance use needs, including the possibility that “alcohol use and street drinking [… are responses] to severe and complex trauma”; and secondly, it ignores the impact that repeatedly trying to curtail their behaviour or banish them from public places (where they may have been planning to sleep for the night and keep all their belongings) would have on people with nowhere safe or private to go.

An alternative type of response which recognises the potentially antisocial impact of street drinking and public injecting, without compromising the dignity of homeless people, is to take consumption off the streets – giving people with substance use problems a ‘safer’ space in which to drink and take drugs where the primary concern is harm reduction rather than deterring use or promoting abstinence.

Taking it off the streets and supervising consumption

Responding to the urgent needs of homeless dependent drinkers are wet hostels or wet day centres which offer shelter, and health and social care support for homeless dependent drinkers, as well as allow them to bring their own alcohol to consume on the premises.

The British legacy includes Providence Row, which opened in 1995 in London’s East End – an area with a highly visible street drinking population. This direct-access hostel differed from most other hostels which had strict requirements around being sober on entry, not drinking on the premises, and addressing drinking problems. Providence Row became an example of how wet hostels could operate safely, enable enhanced care of residents, and reduce street drinking and related nuisance. However, the effective model of support captured in the final evaluation was very different to how the hostel worked when it first opened.

In its first phase the hostel was not seen as a safe environment or as a ‘home’ by residents, and did not provide services to further improve health and tackle problem drinking. This was partly due to unsuitable premises and understaffing, and partly due to management style. However, there were encouraging outcomes in the early days including reduced nuisance from street drinking and begging, hostel staff working closely with local benefits agencies to help residents stabilise their financial situations, and improved health among residents due to them being able to access basic care (such as meals and medication). Further improvements rapidly followed a change in location and a shift in the ‘house rules’:
• In more suitable premises, residents had greater privacy, the layout encouraged natural friendship groups, and the non-institutional design fostered a sense of ownership.
• People who ‘dropped by’ the hostel (as opposed to longer-term residents) were banned, which removed much of the previous disruption.
• The disciplinary code was enforced, rather than excusing residents as ‘unable to control themselves’.

Yet, opportunities for tackling drinking problems and encouraging a more ordered lifestyle were missed, and few female clients were attracted into the predominantly male environment.

A two-part Effectiveness Bank series examined the issues associated with wet centres, which are inherently fragile and difficult to run: “They must be welcoming, yet proactively address anti-social and self-harming behaviour, and do both with low paid and at times inexperienced staff.” Published in 2005, part one dealt with how to plan and set up a service, and part two picked up the story after a centre had become a reality, and staff/management were facing the demanding task of maintaining order yet retaining focus on the more challenging objectives (helping clients control their drinking, and maintaining good community relations).

One of the concerns in the early days of Providence Row was its ‘non-interventionist stance’ on drinking, which spilled over into facilitating drinking and neglecting to provide opportunities for residents to consider routes out of dependence on alcohol. In Canada, their managed alcohol programmes have made facilitating drinking the objective so that staff can effectively monitor residents. A centre in Downtown Ottawa, for example, offers beds and a service where homeless people “can receive ‘15 pours’ of white wine made in-house, between 7:30am and 9:30pm every day”. As a manger explained, “The idea is not to get people intoxicated but to keep them stabilized and not to have them go in withdrawal.”

Managed alcohol programmes emerged in Canada “out of a need for a more compassionate approach to care for people vulnerable to the harms of severe alcohol dependence and homelessness”.

“Toronto’s Seaton House, one of the first [managed alcohol programmes] in Canada, was started following an inquiry into the tragic freezing deaths of three men on the streets of Toronto in 1996. The recommendations from that inquiry were to develop a [24-hour] shelter program for men with severe alcohol dependence. In the early days of that program they began by storing personal alcohol for men so that they would stay inside overnight instead of ending up outside in the snow during freezing temperatures. This gradually evolved into inviting men to stay for breakfast and providing them with a glass of wine to ‘settle their shakes’ while encouraging them to eat. Daily alcohol administration started with one man being offered regular doses of alcohol throughout the day to prevent him from being picked up by the police for public intoxication.”

Primarily tested in community settings, managed alcohol programmes run “on the assumption that the regular administration of a set amount of alcohol will allow participants to stabilise their drinking patterns and avoid some of the harms of excessive alcohol intake”. Within a hospital context, there is also a precedent for providing set amounts of alcohol on a short-term basis to patients with severe alcohol use disorders in order to support those who would otherwise be vulnerable to unmanaged or undermanaged symptoms of alcohol withdrawal, who may resort to non-beverage alcohol consumption such as rubbing alcohol or hand sanitisers, and who would ultimately be at risk from leaving hospital without completing their treatment.

Evidence that managed alcohol programmes can improve the health and wellbeing of homeless dependent drinkers was acknowledged in Scotland’s 2018 Rights, Respect and Recovery drugs and alcohol strategy, which, compared to UK government policy, was more willing to centre harm reduction-based interventions. In the same vein the Scottish Government has expressed support for drug consumption rooms, which are legally sanctioned spaces where people can bring their own pre-obtained illegal or illicit drugs, and either inject or inhale them using sterile equipment under the supervision of nurses or other medical professionals. Minister for Public Health, Sport and Wellbeing Joe FitzPatrick used drug consumption rooms in his opening remarks to the drug and alcohol strategy as an example of “supporting responses which may initially seem controversial or unpopular”:

“Adopting a public health approach also requires us all to think about how best to prevent harm, which takes us beyond just health services. This, requires links into other policy areas including housing, education and justice. It also means supporting responses which may initially seem controversial or unpopular, such as the introduction of supervised drug consumption facilities, but which are driven by a clear evidence base.”

Injecting in public places is a high-risk practice associated with an inability to inject in a sterile way, both due to unhygienic environments and difficulty maintaining personal hygiene, and hasty, unsafe injecting practices due to the threat of being seen by the public or police. People who inject in public places (often young, homeless men) tend to use very large quantities of drugs, inject frequently, share their injecting equipment, and engage in temporary/casual sexual relationships (1 2) – behaviours which place them at increased risk of overdosing, damaging their health in the long term, and acquiring and transmitting infectious diseases.

Drug consumption rooms differ from:
• illegal ‘shooting galleries’ run for profit by drug dealers – though colloquial references to drug consumption rooms in the media can blur this line (1 2);
• hostel or housing services that tolerate drug use among residents but provide no medical supervision;
• programmes which prescribe pharmaceutical heroin (diamorphine) for consumption by their patients under medical supervision (1 2).

Drug consumption rooms are aimed at “limited and well-defined groups of problem drug users” – typically, people who inject on the streets, who are not in treatment, and who are characterised by extreme vulnerability to harm, for example due to social exclusion, poor health and homelessness. The temperament and attitude of staff, as well as the ‘house style’, are critical to whether drug consumption rooms can engage with their target client groups – for example, the extent to which they encourage rather than deter potential clients, and are sympathetic and non-judgemental towards people with multiple and complex problems who may be ostracised in other spaces.

For highly marginalised people who use drugs, drug consumption rooms can be the first step into the health and social care system. Though they do not guarantee that clients access treatment, they do remove some of the traditional barriers to treatment, which can ultimately make treatment a more realistic prospect. To support this suggestion, reviews have consistently found that drug consumption rooms are associated with an increase in the uptake of treatment including opioid substitution therapy and supervised withdrawal (1 2).

The published literature is large and almost unanimous in its support for drug consumption rooms, and there is little to no basis for concern about drug consumption rooms producing adverse effects. On balance, research suggests that drug consumption rooms make drug use safer (eg, increasing access to health and social services, identifying and responding to emergencies, and reducing public drug use), and does not support fears of adverse consequences (eg, encouraging drug use, delaying treatment entry, or aggravating problems arising from local drug markets) (1 2 3).

Time for safer injecting spaces in Britain?

“Drug consumption rooms are not a replacement for abstinence, treatment, or law and order; they provide respite from public injecting, restore a vital connection to healthcare and social support services for a highly-marginalised and highly-stigmatised group of people, and put the interest and wellbeing of people who use drugs at the heart of drug policy. Consistent evidence of their effectiveness suggests that it would be prudent and overdue to trial drug consumption rooms in UK cities.”

An extract from the Effectiveness Bank hot topic on drug consumption rooms.

The chief political defence for drug consumption rooms is to mitigate the public nuisance, disorder and crime associated with public injecting. Compelling evidence about the impact of drug consumption rooms on litter and public disorder comes from Vancouver (Canada), where acceptance of the facility among residents and workers had been generated by the distressing sight of public injecting and injecting-related litter, and despite a large local needle exchange, risky injecting, disease and overdose deaths had remained high. After the facility opened there was a significant reduction in people seen injecting in public places from a daily average of 4.3 to 2.4. Also roughly halved were discarded syringes and injecting-related litter in the surrounding area. In Barcelona a fourfold reduction was reported in the number of unsafely disposed syringes being collected in the vicinity of safer injecting facilities from a monthly average of over 13,000 in 2004 before they opened to around 3,000 in 2012 after they opened (source paper in Spanish).

Police and Crime Commissioners, who would be essential for building local support for drug consumption rooms, have been prominent among those lobbying for the facilities. Several key figures have used their unique positions to advocate for a compassionate and pragmatic harm reduction-based approach to drugs, which they say should include drug consumption rooms. At least four have publicly come forward – the late Ron Hogg (Durham), Arfon Jones (North Wales), David Jamieson (West Midlands), and Martyn Underhill (Dorset) – and seven in total signed a letter to the Home Secretary, Sajid Javid MP, which called on him to end the government’s ‘policy’ of blocking the implementation of drug consumption rooms.

For now the closest contemporary Britain comes to having safer injecting centres are the few clinics where patients inject legally prescribed pharmaceutical heroin (diamorphine) under clinical supervision. These clinics are unlikely to engage the target group of drug consumption rooms, but nonetheless provide a service to people who have not benefitted from more conventional treatment. Furthermore, it could be argued, they provide an experience- and skills-base for drug consumption rooms in the UK as they have to exercise the same monitoring of patients and have the same capacity to respond to overdose incidents as drug consumption rooms.

The UK Government’s approach to illicit drugs is built on the pillars of prohibition and abstinence, which themselves rest on the belief that drugs are inherently harmful to people who use them, and to wider society (1 2 3). However, experiences at the intersection of homelessness and substance use problems show a more complicated picture – the harms of illicit drugs (and indeed alcohol) are not distributed evenly. The environment in which alcohol and drugs are consumed can considerably decrease or increase, mitigate or compound, the harms people experience.

The problem with demanding abstinence

There are legitimate causes for concern about homeless people continuing to drink and/or take drugs, including the risk that their already compromised health could be worsened. However, there are two ways of making sense of the harm, which over the years have vied for space within government policy. The first is to say that harm is ultimately a result of drinking and drug-taking, and therefore we should deter (problematic) substance use, and incentivise or promote abstinence, for example through offering housing contingent on the person engaging with treatment and committing to a new ‘sober life’. The second is to say that harm is more so a result of the environment in which people drink and take drugs, and therefore we should endeavour to change the context in order to make each experience safer, for example through harm reduction approaches such as needle and syringe programmes and providing safe housing. These differences are embodied in the following arguments:

As a population with severely compromised health and wellbeing, homeless people have the most to gain from a life of abstinence.
As a population with severely compromised health and wellbeing, homeless people also have the most to lose from policies that withhold or make it difficult to access life-preserving harm reduction advice and resources.

Of course, there is also room in the middle where a ‘push and pull’ can be seen about how to employ the same interventions and to what end. The most obvious example is opioid substitute prescribing for people dependent on heroin, which in 2014 was subject to intense debate between the Conservative Party and the Advisory Council on the Misuse of Drugs – the former condemning the “routine maintenance of people’s addictions with substitute drugs”, and the latter defending its long-term use, citing strong evidence of an association between time-limited treatment and increased drug-driven crime, overdose deaths, and the spread of blood-borne viruses including hepatitis and HIV. The question here, to which different parties have different answers, is whether harm reduction is a primary goal, a second-best outcome when recovery is for the moment unattainable, or valid only as an engagement strategy and platform for recovery.

In the specific context of how to approach substance use problems among homeless people, there are various problems with insisting on abstinence (including from legal substitutes) as a goal, or casting this as the superior route to recovery, including the way this approach fails to seriously engage with the reasons why homeless people drink or take drugs, how realistic a prospect it is for people with such depleted resources to pursue a narrowly defined version of recovery, and what repercussions this could have on the relationship between homeless people and support professionals (and their subsequent access to support) when they break the ‘rules of engagement’.

“You are made to jump through hoops to prove you’re ready… I must have gone to maybe 20–25 appointments in the last two months… I’ve got nothing to show for any of it, because I can’t stick to appointments… My God, and I don’t have an alarm clock, I don’t have a diary, I don’t have a phone, I don’t have any way to even know what day it is some days.”

Drinking and drug use can be one of the ways that people survive being homeless (eg, keeping warm and passing time), as well as a way to derive some pleasure while homeless, and though it may be uncomfortable to acknowledge, this may remain the case even if people drinking and taking drugs are doing so at harmful levels or through risky means, and may even remain the case among people whose health is already compromised as a result of their homelessness.

For people who were using drugs interviewed for a project funded by the Scottish Executive Health Department, homelessness was an important biographical feature – 32% were homeless at the time of the interview, and 68% had been homeless at some point. Examining this “dual jeopardy of being both homeless and a drug user”, researchers learned that giving up drugs while homeless was an almost impossible proposition, and not only that, for some it was totally undesirable. In these cases, drug use wasn’t an additional burden, it was a vital coping mechanism for them as homeless people; and furthermore, from their lived experience, homelessness and substance use weren’t separate issues, they were woven together.

“When you’re homeless and you’ve got a smack habit [heroin addiction], it’s rough. It’s unbelievable. I don’t know anybody that’s homeless and got a smack habit and that’s happy… You need the smack… I’ve been in some state, but the smack kind of kept me sane. It made me able to handle my homelessness and that… It was the smack that got me through it. It deadened my thoughts and just kind of froze me.” (male, aged 23)
“I’m on the streets so I can’t afford to stop [using heroin]… I’d die of hypothermia or pneumonia or something… I need it [heroin] to keep me going, especially on the streets. It’s not as if I’m in a nice cosy house and there’s plenty of food and you’re not worrying about where to get a sleep and you can sit and watch videotapes all night. I couldn’t lie in that pain [pain caused by heroin withdrawal] in the weather and that. Your body is fighting the elements as well as everything else that goes along with withdrawing. It’s just too much to ask.” (male, aged 32)

Within a harm reduction approach, substance use is accepted “for better or for worse” enabling services to directly “minimize its harmful effects rather than simply ignore or condemn them”. Whether or not total cessation of drug use is objectively ‘best’, harm reduction prioritises the reduction of harms over the attempt to reduce drug use per se. What this can be interpreted as is the belief that drugs may produce harms (as well as benefits), but a fatal overdose or blood-borne virus need not be the price a person pays for taking drugs.

Needle exchange programmes are the cornerstone of harm reduction in the UK. The primary intervention for reducing injecting-related transmission of hepatitis C and other blood-borne viruses, they work by providing people who inject drugs with sterile injecting equipment, as well as infection-prevention and support services (1 2).

When homeless people were surveyed in London as part of a strand of work to map the experiences of hidden homeless populations in 2001, over nine in ten of all those currently dependent on any drug had used a drug service in the last year, but it was mostly confined to needle exchanges rather than drug treatment programmes. Among the 155 people dependent on heroin (using it daily or near daily), needle exchanges were visited by two thirds (62%). The next most popular service was the advice and information drop-in centre (27%), followed by methadone treatment (20%), and residential supervised withdrawal (3%). As well as highlighting the importance of needle and syringe programmes, these figures pointed towards barriers to treatment that homeless people don’t experience (at least to the same degree) with needle and syringe programmes.

Another cohort of homeless people surveyed as part of a six-month pilot between St Mungo’s housing charity and the Camden and Islington Mental Health and Social Care NHS Trust shed light on why accessing treatment can be extraordinarily challenging for homeless people. The most common barriers were:

  1. ‘I can’t make the appointments.’
  2. ‘I can’t get there.’
  3. ‘Too long to wait and too many hoops.’
  4. ‘There’s no point – I don’t want to stop.’
  5. ‘I’ll just get messed about.’
  6. ‘I can never see them when I need to.’
  7. ‘I’ll get thrown out for using on top.’

In the end the project was able to engage and retain this population in methadone treatment, without compromising clinical safety, by addressing the reasons why they had previously not engaged. The clinic was sited within a hostel – providing on-side prescribing, an accessible and co-operative pharmacy, flexible attendance requirements, an open and responsive attitude, and an acceptance of harm reduction goals short of abstinence from illegal drugs. Taking into account the needs, the capacity, and the lifestyles of the population, researchers concluded that, had they adopted an abstinence-based goal and applied a more punitive approach – for instance, making treatment conditional on ‘clean’ urine tests and attending on time – these clients would not have succeeded. They would have been set up to fail yet again, adding to their record of previous treatments and perhaps their characterisation as being resistant to treatment.

A ‘natural experiment’ in the removal of needle exchange services

Until June 2008 Victoria (Canada) had a comprehensive extended hours needle exchange at a fixed site in the city. However, neighbourhood pressure led to closure, creating a natural experiment in the withdrawal of services.

A study featured in the Effectiveness Bank investigated the consequences of the closure – contrasting trends in the sharing of injecting equipment before and after the closure with what happened during the same period in a city which had no such disruption in services.

Taking its data from a twice-yearly survey of adult injectors, over 70% said they were homeless or unstably housed, and about 65% were daily injectors.

Though not statistically significant, in Victoria the proportion having shared injecting equipment rose from 9.5% in early 2008 just before the closure to 20% in late 2010, while in Vancouver the proportion remained relatively steady at under 10%.

A Consensus Statement on Best Practice published by three leadingThe National Needle Exchange Forum, UK Harm Reduction Alliance, and Exchange Supplies. organisations in harm reduction identified the essential elements of harm reduction as the provision of sterile injecting equipment, facilities for the safe disposal of used equipment, and substitute prescribing such as methadone. Despite the difficulty of providing definitive proof, the evidence has been enough for UN agencies and other authorities to promote needle exchange and substitute prescribing as ways to curb the spread of blood-borne viruses including hepatitis C. Posed the question, “What level of coverage should needle and syringe programmes provide to keep HIV prevalence low and to reduce the prevalence of hepatitis C among people who inject drugs?”, Britain’s National Institute for Health and Care Excellence (NICE) called on commissioners to aim to provide more than enough needles and syringes for every injector to be able to use a sterile set each time they inject.

In some localities, changes in circumstances have been suggesting that a different or intensified response to blood-borne viruses is needed. For example, in Glasgow city centre there were 47 new diagnoses of HIV among people who inject drugs in 2015, compared to an annual average of 10. This problem caught the attention of the European Monitoring Centre for Drugs and Drug Addiction, which reported 119 new cases of HIV in Glasgow between November 2014 and January 2018, specifically among homeless people who inject drugs. The agency described this as “the largest cluster of people who inject drugs infected with HIV…in the United Kingdom since the 1980s”.

An important feature of this outbreak was its strong link to cocaine use, which surveillance data from needle and syringe programmes using dried blood testing and data from syringe residues in 2017 indicates is increasingly being injected (with or without heroin). Critically, harm reduction services (including the provision of injecting equipment and opioid substitution treatment) were available before and during the outbreak; needle and syringe programmes in Glasgow distribute over one million syringes per year.

In Taking away the chaos, the local health service and Glasgow’s drug service coordinating partnership reviewed the health and service needs of people who inject drugs in public places in the city centre. Resulting recommendations were to develop existing services, including extending assertive outreach services and developing a peer network for harm reduction, and to introduce new services, such as a pilot safer injecting facility in the city centre to “address the unacceptable burden of health and social harms caused by public injecting”. However, to date the Scottish Government has been constrained by legal judgements that drug consumption rooms would fall under the purview of the UK Government (and UK-wide Misuse of Drugs Act 1971), which has repeatedly said it is ‘unwilling’ and ‘unable’ to change its position on drug consumption rooms.

One of the lifesaving resources used inside drug consumption rooms, and increasingly on the streets, is the ‘overdose antidote’ naloxone, which is an effective and rapid way of reversing the effects of opioid overdose. Naloxone can be administered in a range of ways (via needle straight into the vein, muscle or under the skin, or nasal spray) depending on the setting and skill of the person. Experts convened by the World Health Organization have judged the “risk-benefit profile to be strongly in favour of naloxone distribution, due to its clear potential for saving lives and apparent low risk of significant adverse effects”, and strongly recommend naloxone provision and associated training for people likely to witness an opioid overdose.

In 2005 naloxone became the new hope for harm reduction after UK law was amended to permit emergency administration by any member of the public. Its legal approval was seen as an important step to widening availability – meaning that GPs could prescribe kits to suitably trained drug users, friends and families. Scotland lifted these restrictions further, allowing emergency-use naloxone to be provided to services without prescription, enabling drug treatment and homeless hostel staff to have the drug ready for use. National naloxone programmes have been in place in Wales and Scotland since 2011. In the name of localism England has so far not established a centrally driven national programme. However, as of 2019, the nasal spray format was being trialled in a pioneering way by police officers in West Midlands Police, providing a potential model for other police forces and professionals who come into contact with people who inject in public places, such as the homeless. The UK’s first naloxone peer training and supply programme has also been launched in Scotland, where it is hoped that “volunteers will contribute to increasing the availability of naloxone within the community so that it is more likely to be present when an overdose occurs”.

Fatal overdoses and blood-borne virus are the ‘headline’ harms among people who use drugs. For homeless people in particular, but people who use drugs more generally, there are many other conditions that harm reduction approaches seek to prevent by radically changing the conditions in which drugs are taken, including skin and soft tissue infections at injecting sites, infective endocarditis, sepsis, and bone and joint infections.

Although ensuring adequate provision of harm reduction resources may be thorny from a policymaking and funding context – remembering it is an ideologically contested approach to drug and alcohol problems in society – without it homeless people will be denied the very ‘basic’ right to be able to protect themselves from harm. Harm reduction can save lives, and along with other essentials such as housing could dramatically improve quality of life (1 2 3).

The right foundation for recovery

The most obvious solutions to homelessness are to stop people from losing their homes in the first place, and to swiftly provide housing where people are in need. This alone requires substantial work across a range of housing policy areas – for example, ensuring the provision of emergency accommodation for people needing refuge or transitioning from institutional care such as prisons or hospitals, or being discharged from the armed forces, building sufficient social housing stock, and cultivating a private rented sector that protects the rights of tenants. However, needs also run deeper than bricks and mortar. As suggested by the deep social exclusion and disadvantage that often accompany homelessness, people may require long-term interventions to address their housing needs along with their health and social care needs.

People with drug and alcohol problems can struggle to access accommodation on the open housing market, requiring a range of practical interventions, from assistance with rent arrears and finding a deposit, to finding emergency or transitional accommodation. They can also struggle to sustain accommodation without ongoing help, but be excluded from models of supported accommodation due to their lifestyle and current patterns of substance use – either explicitly because they don’t meet conditions for abstinence, or implicitly through being unable to follow ‘house rules’ such as not being intoxicated on the premises.

Offering destitute people access to housing if they stay drug free is a powerful incentive, and there is some evidence that among poor people enmeshed in illegal drug use, housing motivations can help initiate and extend drug-free periods. However, intensive support tends to be needed to maximise and maintain the benefits once incentives are withdrawn, and it seems that offering decent, affordable housing itself without requiring abstinence has in the longer term been just as effective as making these benefits contingent on abstinence.

As evidence shows that services requiring abstinence do succeed with at least a minority, there would seem to be a need for either a mixture of services, or a flexible model which can accept when harm reduction and semi-independent living are the only realistic goals, but can also pursue abstinence and independent living where appropriate. However, offering this mixture within the same service is problematic. Within housing services, ‘proximity’ between people with different goals or current substance use habits can exacerbate problems – increasing proximity to drugs, and therefore increasing their temptation to use, and increasing proximity to the negative consequences of drug use such as violence and overdoses.

Based on the views of homeless people who use drugs, a list of good practice recommendations for hostels housing people recovering from and/or currently struggling with problematic drug use has been developed. The guidance, summarised by the European Monitoring Centre for Drugs and Drug Addiction, highlights the need for:
✔ good-quality housing (clean, in good condition);
✔ provision of basic amenities (eg, toiletries);
✔ flexibility of rules regarding curfew, meal times and visitors;
✔ a recovery-oriented environment (separation of drug-using and non-using residents, and prohibition of open dealing);
✔ tailored support for residents (medical services, treatment, harm reduction advice, and further social reintegration activities);
✔ respect for residents’ privacy (eg, in relation to room searches);
✔ the professional conduct of staff (friendly, non-stigmatising, and abstinent).

Insistence on abstinence as a condition for housing rules out anyone unable or unwilling to abstain from drinking or using drugs, and without feasible housing alternatives, may consign them to sleeping rough. Even among homeless people with the desire and the motivation to ‘achieve’ abstinence, making an offer of housing contingent on substance use status requires them to address their substance use problem while homeless – and potentially without even a roof over their head – which people with lived experience of homelessness and substance use dependence attest is virtually impossible. Services which impose rigid predetermined requirements or predetermined goals of abstinence or independent living therefore risk being unrealistic for many actual or potential service users.

‘Housing first’ approaches attempt to undo this bind by integrating housing and harm reduction support and delivering these regardless of current substance use, as opposed to traditional ‘treatment first’ approaches, where there is a requirement to engage with treatment before accessing housing or housing support, or making housing contingent on acceptance of treatment.

The housing first model originated in the United States, based on the view that a home of your own (and, within normal constraints, of your own choice) is a right regardless of whether you have accepted help with (still less succeeded in) resolving substance use and other problems. In the UK, examples of housing first have followed a ‘Europeanised’ approach – “giv[ing] service users full housing rights and deliver[ing] a greater degree of choice … than was the case for US pioneer projects” ( see the seven principles of housing first).

The seven principles of housing first

  1. People have a right to a home.
  2. Flexible support is provided for as long as it is needed.
  3. Housing and support are separated.
  4. Individuals have choice and control.
  5. Staff are responsible for proactively engaging their clients; making the service fit the individual instead of trying to make the individual fit the service.
  6. The service is based on people’s strengths, goals and aspirations.
  7. Staff support people who drink and take drugs to reduce immediate and ongoing harm to their health.

In the UK, housing first uses a client-led approach: people using housing first services exercise choice and have control over their own lives, and do not have to be ‘housing ready’ before they are offered a home. Housing and support are also separated, so getting access to housing and remaining in housing are not conditional on accepting support or treatment.

The target group for housing first is people with sustained and recurrent experiences of homelessness, who also have high and complex support needs. In nine UK servicesFive services were operating in London, two focused on the boroughs of Lewisham and Redbridge. There were also services in the North East (Newcastle upon Tyne), the Midlands (Stoke-on-Trent) and on the South Coast (Brighton and Hove and in West Sussex). None of the housing first services were in rural areas. evaluated in 2015, clients presented with several of the following support needs: severe mental illness or mental health problems; drug and alcohol problems; poor physical health, including life-limiting illnesses; physical disabilities; high rates of contact with the criminal justice system; sustained experience of unemployment; limited educational attainment; poor social supports (ie, lack of friendships, a partner and contact with family members); challenging behaviour; and learning difficulties. Furthermore, clients came to the service with histories and circumstances (other than current substance use) that would count as strikes against them in other housing models; they were exhibiting anti-social behaviour, had criminal records, were not in receipt of treatment for current mental health problems, had a history of rent arrears, and had a history of arson.

Overall, housing first has been shown to improve stability of housing, even when substance use stays relatively unaffected, and is more effective at maintaining engagement with homeless people than abstinence-based services. In the UK specifically, there is evidence that it works well in reducing long-term homelessness, and can successfully engage with people who have very long-term histories of contact with other forms of homelessness service (without their homelessness having ever been resolved).

The strong evidence that housing first can end homelessness among people with multiple and complex needs applies to (but is not limited to) the population at the centre of the featured hot topic – people who are homeless with substance use problems. However, there can be a lack of clarity in the discourse about what the ultimate goal of housing first is for this client group; specifically, what yardstick we should use to judge the success of housing first.

Is the aim first and foremost to ensure that vulnerable people become and stay housed?
Or should the goal be for people to show movement on their substance use outcomes – moderating their use, showing less dependence, becoming abstinent, using in a less risky way etc.?

People who are required to comply with abstinence-only living are affected to a greater degree when they do not ‘succeed’ at tackling their substance use problems. Due to support and housing being kept as separate entities in housing first, a lack of engagement with treatment does not lead clients down an inevitable path of losing their housing.

On the basis of evidence published up to 2009, reviewers concluded that it would be premature and possibly risky to routinely apply housing first to people with substance use problems. However, since then several studies have affirmed housing first’s ability to provide housing stability for previously homeless people with substance use problems, and has shown promise in at least securing engagement with a group of people for whom this is typically difficult within traditional dynamics of support (1 2 3).

Very few studies have used a randomised controlled trial format to investigate the effectiveness of housing first – the ‘gold standard’ for determining whether an intervention actually caused the desired changes. What studies tend to do instead is compare the outcomes of people entering housing first under real-world circumstances versus people participating in treatment as usual in the local area, meaning that the characteristics and motivations of the two different groups may be different to begin with, and changes/improvements in their housing, health, and social outcomes may not come (solely) from the support they received.

Of the very minimal data about housing first available from randomised controlled trials, there were reductions in problem substance use for both housing first and treatment as usual groups, with no clear difference between them. While this does not suggest that housing first is associated with superior substance use outcomes, it does at least rebuff concerns that without treatment/abstinence conditions housing first programmes will cause people’s substance use problems to worsen. Across all studies, not limited to those reporting substance use outcomes, there was also evidence of housing first having a significant impact on healthcare by reducing the use of non-routine services, including episodes of hospitalisation and use of emergency services.

Among studies not using a randomised controlled trial design, housing first was strongly associated with favourable long term substance use outcomes in one study based in New York City. This evaluated the Keeping Home project, a housing first programme which secured market-rate apartments and assertive community treatment support to patients with serious mental illness who were on methadone maintenance treatment. Compared with a group of clients drawn from an administrative database with similar characteristics who were also (at least initially) in methadone maintenance treatment, at three years after the start of the programme retention in methadone treatment was significantly higher in the housing first group (52% vs. 20%), as was retention in housing (68% vs. 3%).

In another study set in New York City there were notable differences in substance use outcomes, for example housing first participants were significantly more likely to have low/no substance use during the study year than the treatment first participants, and were significantly less likely to use services for substance use and less likely to prematurely leave their programme. However, the researchers suggested that these findings were probably a reflection of lower need among the housing first population, and of housing first offering a harm reduction approach that tolerated low to moderate use without mandating treatment for withdrawal and rehabilitation. In this case, of the eight housing first participants who reported using substances, all stayed enrolled in the programme including two who reported a relapse into dependence. Three housing first participants left the programme prematurely, but joined family outside of the city or state and did not report relapsing. In contrast, of the 31 in the treatment first group who reported using drugs and/or drinking during the study, 26 left the programme prematurely and five were discharged. A total of 14 experienced a relapse. More so than demonstrating the effectiveness of housing first, this study may point towards the problem treatment first programmes can have in retaining clients, and helping them to avoid substance use and possible relapse despite these being the overt aims.

In Canada, a study found that housing first was consistently associated with positive housing outcomes compared to standard care in the community. The housing first group was significantly more likely to achieve housing stability than the comparison group: they spent more time stably housed over the previous two years, they reported more days consecutively housed, a greater percentage of clients were housed for the entirety of the last six months, and were less likely to be homeless during the period. However, housing first was not associated with the same degree of success for substance use outcomes. Both groups reported significant decreases in drinking problems and in the numbers reporting severe alcohol use, with no significant difference between the two groups. Furthermore, although both groups reported a decrease in problems associated with drug use over time, the comparison group had significantly fewer problems with drug use than the housing first group at 24 months.

Most recently in 2019, a randomised controlled trial in a small Canadian city found that, compared with treatment as usual, housing first was associated with participants exiting homelessness more rapidly, spending a greater proportion of time in stable housing, experiencing fewer moves, and being much more likely to be housed consecutively for six months or more. Furthermore, housing first participants rated their housing higher in terms of safety, spaciousness, privacy, friendliness, and overall quality. While the sample of participants was not exclusively people with substance use problems, a large proportion of participants were dependent on alcohol (31% housing first and 32% treatment as usual) or other substances (55% and 51%). Severity of substance use problems was one of the secondary outcomes. On this, there was no significant difference between groups – both showed significant improvements in substance use problems, which may have been accounted for to some extent by ‘regression to the mean’ – “with participants entering the study at a particularly difficult point, and returning, on average, to a higher level of functioning over time”.

The bulk of research to date has been concerned with the application of housing first in North America, and among people who have mental health problems. Although substance use problems are also common they have only been the main focus in a handful of studies. Further research is needed to quantify or qualify the impact of housing first interventions on substance use outcomes and for people with substance use problems.

That housing first should replace other homelessness services has not yet been borne out by the evidence. However, governments across the UK have accepted it as part of the solution to homelessness. For the UK Government, housing first is part of the plan to end rough sleeping by 2024, and is being supported initially with £28m of funding for housing first pilots in Greater Manchester, the West Midlands and Liverpool; the Welsh Government is funding 10 housing first projects and endorses housing first as a solution to long-term chronic rough sleeping; and, the Scottish Government is piloting housing first in five of its biggest cities (Aberdeen, Dundee, Edinburgh, Glasgow, and Stirling) through the Housing First Pathfinders programme, which is “working to make Housing First a reality on a much bigger scale than what we’ve so far known”. It is not yet clear how aware the general public is of housing first-type solutions to supporting vulnerable people, and why these are necessary. Due to negative perceptions held about homelessness, for example its association with hardship due to ‘poor choices’ and ‘bad luck’, the general public may need convincing that with the right support at the right time, ending homelessness is actually achievable.

Shifting public perceptions of homelessness

Investigative work from Crisis revealed that the kind of bottom-up momentum needed to generate progressive policies for homeless people has been impeded by the mismatch between the way the public understands homelessness, and the intentions experts have for communicating about it. Zeroing in on the problem they found that the public is unable to identify with or relate to the most common depictions of homeless people.

The dominant stereotype of a homeless person is a middle-aged man between the ages of 40 and 60 who has been sleeping rough for a long period of time and has serious problems with his drinking, drug use, and mental health. According to Crisis, this and other stereotypes of homeless people – including the young person who has been kicked out by their family and is living on the streets, and the abused woman who was forced to leave home – have a counterproductive effect, making it difficult for members of the public to understand unless they too have experienced something similar.

Though no doubt from a well-intentioned place of trying to help homeless people, narratives of them being in extreme hardship with nowhere left to turn can elicit fatalistic attitudes, embedding the view that homelessness is an unavoidable and limiting support for solutions. This is one of four areas of public perception ( see list) that Crisis believes could be targeted in order to shift public perceptions of homelessness in a positive direction .

What we need to address about public perceptions of homelessness

Homelessness charity Crisis has identified four areas that need to be targeted in order to shift public perceptions of homelessness:
• the narrow definition of what homelessness is and who is affected;
• the poor understanding of ‘prevention’;
• the tendency to view homelessness through the lens of individualism;
• limited support for solutions due to people feeling fatalistic about homelessness.

On-the-street interviews with 51 people, and surveys with a nationally representative sample of 9,900 respondents, identified that tapping into a “common experience” frame of reference would be the most effective strategy for changing public perceptions. This would work by highlighting our fundamental commonalities (ie, homeless people are human beings and members of society, and not somehow ‘other’), communicating the experience of what it is like to be homeless, describing how homelessness occurs, and explaining how systemic solutions can help.

The common experience frame was not equivalent to the message that ‘homelessness can happen to anyone’ – inherent in claims such as ‘we’re all only a few pay cheques away from homelessness’. When this type of message was tested, it failed to positively shift people’s attitudes. One of the theories researchers had about why this was ineffective was that people’s experience was telling them that in fact not everyone is at real risk of becoming homeless as they have the resources and support structures that would prevent this from happening.

Thinking about the values that underpin effective messaging, the research identified the following as helping to shift public attitudes about homelessness:
“Everyone has the right to be treated with dignity.” Activating this value had a strong, statistically significant effect on participants’ attitudes and was equally powerful among voters from across the political spectrum.
“What affects one of us affects all of us. When some people are struggling, it hurts everyone.” Triggering this value had significant effects on recognition of the importance of addressing homelessness. It was also the only value that increased people’s understanding of the systemic causes of homelessness.

These values were hinted at in the foreword to the 2018 Rough Sleeping Strategy. James Brokenshire MP (then Secretary of State for Housing, Communities and Local Government) affirmed that “Central and local government must work together to ensure everyone in our society has the dignity and security they need.” Though words surely welcomed by key stakeholders, there may be some apprehension about the level of central government commitment to ending homelessness given the adverse impact of policy and funding decisions within recent memory on the root causes of homelessness and substance use problems, and on the capacity of frontline services to meet the needs of this population.

Changing lives in the age of austerity

The UK Government pledge of £100m to end rough sleeping by 2027 marks an ambitious (and much-needed) attempt to address the individual and societal burdens of homelessness. However, humming in the background of the government’s expressed ambitions are the significant cuts to public spending in the name of austerity, which have (1 2):
• directly impacted homelessness services, as well as drug and alcohol services – undermining their ability to deliver treatment support to the group of people at the centre of the featured hot topic;
• exacerbated the conditions that lead to homelessness, including people living below the poverty line (eg, due to cuts to working-age benefits and tax credits) and being unable to access basic financial support, healthcare, and social care.

The term ‘austerity’ is defined as “a situation in which people’s living standards are reduced because of economic difficulties”. What the definition obscures about the austerity measures in recent memory is that austerity doesn’t affect everyone’s living standards, nor to the same degree. Not everyone has been ‘tightening their belts’; some people have found it increasingly difficult to survive, for example resorting to the use of food banks. Between April 2018 and March 2019, the more than 1,200 food banks supported by the charity The Trussell Trust provided a record 1.6 million food supplies to people in crisis – a 19% increase on the previous year.

Speaking to the website Politico in December 2018, the minister with responsibility for housing James Brokenshire acknowledged that Tory policies may have played a role in the huge increase in rough sleeping in recent years. Brokenshire said, “[we] need to ask ourselves some very hard questions” about why so many more people are now living on the streets than when the party came to power, and admitted “changes to policy” were needed.

In 2017, the Advisory Council on the Misuse of Drugs (ACMD) warned that the drug and alcohol treatment sector has faced a “disproportionate decrease in resources, likely to reduce treatment penetration and the quality of treatment in England”. Citing an analysis from the King’s Fund, the ACMD reported that drug misuse treatment was looking at a higher percentage reduction in planned spending than other public health areas in 2016/17, which would translate into larger absolute reductions in planned spending. Between 2015/16 and 2016/17, there was an anticipated 14% reduction in drug misuse funding, slightly more than a 9% reduction in young people’s substance misuse services funding, and a circa 7% increase in planned alcohol misuse funding. Spending on housing services (including homelessness and housing benefits) was also down by 7.5%. Commenting on the treatment landscape, Annette Dale-Perera, chair of the ACMD’s recovery committee, said:

“A lack of spending on drug treatment is short-sighted and a catalyst for disaster. This system is now being dismantled due to reductions in resources. Unless government protect funding, the new [UK] drug strategy aspiration of ‘effectively funded and commissioned [drug treatment] services’ will be compromised.”

The ACMD also found evidence that under-resourcing was compromising the quality and effectiveness of drug misuse treatment. There were, for example, serious concerns among commissioners about the balance of clinical and professional expertise, and whether staff and volunteers were being lost due to financial constraints. The State of the Sector reports, which provide a detailed insight into the changing nature of drug and alcohol misuse treatment services from a provider perspective, found in 2015 that there was a 53% reported reduction in frontline staff and a 62% reported increase in the use of volunteer recovery champions. Additionally, the Royal College of Psychiatrists gave evidence that some services had been re-procured for 30% of the cost for the same number of patients. They drew attention to the loss of costlier professional staff, for example clinical assistants replacing consultant psychiatrists, and peer mentors replacing nurses and psychologists.

Showing the reverberations of public spending cuts throughout the drug and alcohol sector, the Independent found that anticipated spending of their grant on residential detoxification in 39 councils was £9.76m in 2017/18, compared with the £12.92m spent four years previously. This represented a cut of more than £3m and a 24% reduction. Mike Pattinson, executive director of Change Grow Live, one of the largest drug treatment providers in England, told the Independent that residential centres continued to play an “integral role” in treatment. “Whilst it is true that residential treatment is more expensive than community-based options, in some circumstances it remains entirely appropriate and can be lifesaving.” In 2019, the picture remained bleak, with the Independent reporting that the number of live-in drug and alcohol rehabilitation services in England had fallen by one-third in six years. There were 195 residential rehabilitation and detox services registered with the Care Quality Commission in England in 2013, but by 2019 this had fallen to just 132 active centres.

Ambitions to ‘end homelessness’ and support people to pursue ‘full recovery’ convey a vision of a better society – but exactly what we mean by these statements and how we intend to get there are more important than the headlines. What we want is the proviso that ‘no people were harmed in the making of these policies’; that these policies don’t do harm while trying to do good. Given the landscape to date, it would be prudent to move forward asking what values underpin housing, drug, and alcohol policies, and how future policies will feel from the perspective of people living with the daily reality of homelessness and substance use problems.

A ‘dignity first’ approach to homelessness, drugs, and alcohol


Effectiveness Bank hot topics cover issues which prompt heated debate. The present hot topic focused on people with experiences of homelessness and substance use, examining what social policies would look like if they prioritised saving lives and improving lives.

One of the major obstacles to progressive policies for this population is the public disorder lens through which homelessness and substance use problems tend to be viewed – in particular the most visible expressions of homelessness and substance use problems. Rough sleeping, street drinking, and public injecting have been cast in the public imagination as ‘antisocial street lifestyles’; the most charitable interpretation being an unfortunate state of extreme hardship, and at the sharp end, a choice not to be part of mainstream society.

As behaviours such as rough sleeping, street drinking, and public injecting occur in shared social spaces, the antisocial impact they have on others can sometimes appear to outweigh their existential threat to homeless people. While policymakers may feel obliged to respond to the interests of both groups, and especially in the short term to pacify the voting public, the public health consequences associated with drinking and drug use among homeless people (some of which were documented in this hot topic) mean that we should not be talking about these two distinct groups as if their interests are equally important.

Some of the issues at the junction of homelessness and substance use problems are complex, requiring multifaceted interventions aimed at individuals, the culture, the environment, and institutions. However, there are also very ‘basic’ things that we know can improve and save people’s lives: food, shelter, healthcare, protection from violence and abuse, and access to lifesaving advice and resources.

The rejection of pragmatic harm reduction approaches in favour of deterring people from drinking and taking drugs altogether – which in theory if everyone stopped consuming would eradicate rather than reduce drug- and alcohol-related harm – has also been a considerable impediment to saving lives and improving lives, overlooking the immediate needs of homeless people.

Harm is experienced by people as a result of drinking and taking drugs, and as a result of the environment in which they drink and take drugs. For homeless people in particular it would seem that the latter is the deadly ingredient. Policymakers should be particularly sensitive to the fact that the environment and the context in which homeless people drink and take drugs is very different to the general population, and their rejection of or inability to access treatment should not be met with a refusal to look after them in their current position. Policies should address both these sources of harm in order to meet both the urgent and the long-term needs of homeless people.

The most obvious solution to homelessness is the provision of appropriate housing. However, the most obvious solution is in this case too simplistic. Housing provides shelter, but does not guarantee that someone will be able to maintain a roof over their hard. Homelessness combined with substance use problems signify deep social exclusion, and housing alone cannot tackle the reasons why some people are vulnerable to becoming and remaining homelessness.

Housing is an essential source of stability, safety, and security, making recovery a more realistic prospect. It is also more than a lever for producing positive substance use outcomes. Access to housing improves the general wellbeing and living standards of people with substance use outcomes, which should be considered a worthwhile endeavour whether it improves their substance use outcomes or not.

“Everyone needs a safe, warm place they can call home. Home is more than a physical place to live. It’s where we feel secure, have roots and a sense of belonging. Home supports our physical and emotional health and wellbeing and to be without one seems unthinkable.”

Few of us know the demands of homelessness or what it takes to survive, and more often than not those put in the position of making policy and funding decisions have the privilege of distance from the day-to-day realities of homelessness. The inherent danger of this is that policies designed to fix the problem continue to (re)produce the inequalities that cause it. The ‘temperature check’ of all policies should be that they uphold the dignity of disadvantaged and socially excluded people. A dignity first approach to homeless people who drink and take drugs prioritises saving lives and improving lives.

Thanks for their comments on this entry in draft to Oliver Standing (Director, Collective Voice), Dr Ira Unell (consultant and lecturer in substance use and homelessness), Becky Elton (Executive Director Operations, Changing Lives), and to Collective Voice and Homeless Link for inviting Drug and Alcohol Findings to a roundtable discussion on the application of housing first to clients with drug and alcohol problems. Commentators bear no responsibility for the text including the interpretations and any remaining errors.

Last revised 31 January 2020. First uploaded 16 July 2019

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