Homeless, Mentally Ill and Addicted: The Downward Spiral

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Photo by flightlog via Flickr

Several states are in the midst of hepatitis A virus outbreaks. San Diego and the surrounding region are among the hardest hit, but southeast Michigan has more reported cases and more deaths. Utah, Colorado and Kentucky also have experienced outbreaks.

California had 683 cases as of Jan. 23, with 21 deaths. Michigan recorded 715 cases as of Jan. 24, with 24 deaths. Colorado has had 62 cases, and one reported death.

Understanding these outbreaks requires acknowledging the links between homelessness, addiction and mental illness—and it requires more than a single solution.

Hepatitis A is typically a disease spread by human contact with already-infected individuals or pieces of their stool that are too small to see. High-risk groups include the homeless, the incarcerated (and those released from prison) and drug users—all groups that have some overlap. The homeless and the incarcerated also suffer from mental illness and are drug users, a condition known as a dual diagnosis or co-occurring disorders, and the deficiencies of health care in many prison facilities make incarceration a key risk factor.

According to a 2009 National Coalition for the Homeless (NCH) fact sheet, the Substance Abuse and Mental Health Services Administration found that “20 to 25 percent of the homeless population in the United States suffers from some form of severe mental illness,” compared to only six percent of the population as a whole.

A one-year study of people with serious mental illnesses examined by California’s public mental health system found that 15 percent were homeless at least once in the previous 12 months.

In addition, the NCH fact sheet found that “some mentally ill people self-medicate using street drugs, which can lead not only to addictions, but also to disease transmission from injection drug use.”

The Los Angeles Times cites experts who say that 50 percent to 70 percent of homeless people with severe mental illness (SMI) also have problems with alcohol or drugs.

The likelihood of homelessness also is increased when you have a mental illness, an addiction disorder and a disease such as hepatitis A. None of these conditions is going to go away if you are homeless and have no access to health, substance abuse or mental illness services.

If only one of the three gets treatment, the other two remain, and the third may return because they are all connected.

In 2016, Kevin Fischer, executive director of the National Alliance on Mental Illness (NAMI) of Michigan, suggested on Michigan Public Radio that closing all the state mental hospitals in the 1990s by then-Gov. John Engler resulted in an “explosion in homelessness.”

The mentally ill were supposed to be sent home, but many ended up on the streets because the private mental health system and the patients’ families were not prepared to handle them.

Joel John Roberts, CEO of People Assisting The Homeless (PATH) Partners, says many people in the mental health field put the blame on Ronald Reagan, then governor of California, who they say released more than 50 percent of the state’s mental hospital patients and abolished involuntary hospitalization of people with mental illness.

“This started a national trend of de-institutionalization,” Roberts wrote.

Then, as president, Reagan ended funding for federal community mental health centers. No one expected the mentally ill to wander the streets. The feds thought the states would take care of them. The states thought private insurance or family would take care of them.

Somewhere, somehow, they were wrong.

To get these outbreaks under control, and to prevent future outbreaks, we need more support for mental health and substance abuse treatment, and better harm reduction strategies (including clean needle exchanges and safe injection sites).

Some of that funding could come from Medicaid if the Trump administration eliminates the Institutions for Mental Diseases (IMD) Exclusion, which prohibits Medicaid funds going to mental health providers with more than 16 beds. There’s bipartisan agreement that this rule, which dates back to 1965, needs to go. The executive branch can, has, and does issue exemptions for this rule, and Trump has pledged to speed up the process.

But virtually no one thinks the rule needs to remain.

More than money is needed. Sometimes only one co-occurring disorder is apparent. First responders need to be trained to look for and recognize both.

In 2017, the Michigan Department of Health and Human Services (MDHHS) & Michigan Association of CMH Boards wrote, “Supports and services for persons with co-occurring mental health and substance use disorders must be the norm for all agencies across the network.”

The department added this was because “it is more prevalent than addiction-only or mental illness-only among the people served by MDHHS providers. Practitioners in every program at all levels of care must be competent to address comorbidity in mental health and substance abuse treatment.”

Effective treatment, according to the NAMI, requires not only that both be treated—but preferably at the same time. It’s called integrated intervention, and often involves detoxification, inpatient rehabilitation with psychotherapy, supportive housing, maybe medications (either to treat mental illness symptoms or to control addiction) and self-help/support groups.

The Michigan House of Representatives’ bipartisan House C.A.R.E.S. (Community, Access, Resources, Education, and Safety) Task Force’s final report recommended that crisis intervention training (CIT) for first responders should include “information on signs and symptoms of mental illnesses” and “co-occurring substance use disorders.”

It also recommended that trial and pre-trial practices “should assess defendants to determine whether the person has a serious mental illness, co-occurring substance use disorder” and so benefit from “mental health services.” Better and more consistent efforts must be made to screen for mental illness and co-occurring substance disorders during the booking process, the task force said.

But that’s if the individual ends up in the mental health or criminal justice system. There are harm reduction practices that can save lives even if the person with mental health and substance-use disorder remains out of the system.

One is providing maintenance drugs (medication-assisted treatment or MAT) such as buprenorphine (brand name Suboxone, also available as an implant, Probuphine, that only needs to be replaced every 90 days) or methadone to addicts to prevent withdrawal, and there are drugs for mental illnesses such as depression, bipolar disorder, schizophrenia, and psychosis.

Another—although hep A isn’t as likely to be spread this way—is providing intravenous drug users with a safe injection space. These spaces are also known as safe consumption sites, fix rooms, drug consumption room (DCR), supervised injecting facilities, and shooting galleries. But they share the following characteristics: a clean facility, with clean needles, the availability of testing supplies to make sure the drug is unadulterated, and a nurse to administer naloxone in case of an overdose.

They not only save lives—no deaths have been reported at any such site around the world, including Canada and Australia—they also save money.

Editor’s Note: San Francisco is set to become the first in the U.S. to introduce safe injection spaces, with two sites scheduled to open in July.

A recent study estimated that such strategies could save an average US city $3.5 million per year and that some could save more (Baltimore: $6 million). The American Medical Association likes the idea, as do the Clinton Foundation and the Johns Hopkins Bloomberg School of Public Health.

Some in the anti-drug camp oppose harm reduction in particular, and substance abuse treatment in general. They prefer incarceration to rehab. Their position on the mentally ill is less clear, but maybe they feel that, too, is the result of a poor personal choice.

Stephen Bitsoli

Stephen Bitsoli

Maybe paying for these sinners to go to dual diagnosis treatment centers seems like rewarding bad behavior. The result: we have a homeless problem, an opioid epidemic, and hepatitis A outbreaks,

Punishment isn’t working, and science and public opinion now believe addiction is like a disease. It’s time to look for compassionate, evidence-based solutions.

Stephen Bitsoli, a Michigan-based freelancer, writes about addiction, politics and related matters for several blogs. He welcomes readers’ comments.

6 thoughts on “Homeless, Mentally Ill and Addicted: The Downward Spiral

  1. After experiencing chronic homelessness and some years of problematic drug use I ended working for some time in homeless services and recovery services. During this work I often questioned the common narratives surrounding drug use and homelessness, questioning the need for some called enhanced shelters and services, as my experience on the streets didn’t jibe with the explained causes of homelessness being primarily mental illness and drug use. I watched many new faces on the street slowly change from energetic and hopeful souls to persons whose mental health deteriorated from the constant barrage of stigma and criminalization, often watching them turn to drug use to help with the pain they felt as marginalised and disposable bodies, no longer members of the society which scorned them. I felt very alone in my analysis of the service system I grew to despise. I slowly came to understand how our neoliberal rulers, whose economic policies are the true cause of homelessness, had pushed this mythic need for more and more enhanced services in order to build another million plus dollar industry around the farce of “ending homelessness “. I finally found others who shared my analysis and decided to leave the service system and truly work for social justice. This paper helped me solidify my analysis https://www.google.com/url?sa=t&source=web&rct=j&url=http://depts.washington.edu/relpov/wordpress/wp-content/uploads/2013/12/Sparks-governing-homeless.pdf&ved=2ahUKEwiYjKzy15bZAhUSXa0KHVqBAWs4ChAWMAB6BAgTEAE&usg=AOvVaw1-VE2JQ9N1bhSsv97sa-Lk I hope people will take more care in spreading these damaging and false narratives about homelessness.

  2. Portugal is held up as the gold standard for “decriminalizing” drugs and not “judging” the addict. Their programs has some success due to wrap-around services and is mandatory. Portugal does not have a “Safe” Injection Program. Drug dealing is still illegal and dealt with harshly. Other EU countries tried to emulate the program. With the 2008 recession, their budgets were slashed for the addicts in program and caused overdoses, increased crime, and increased disease transmission, increased homelessness. Can you see us having an Injections Site AND wrap-around services? I don’t believe there will be funding for both. Why not use any proposed funding and increase needed detox/rehab facilities and sober living environments along with all the needed physical/mental health and social services. The way I see it, Injections Sites are prolonging the suffering and misery of the addict with the usual end result of death. Which would be more compassionate?

    [this comment has been edited for space]

  3. SISs are a bad idea. They perpetuate the misery of the addict by giving up on them and expect that there is no help for them except to die an eventual early death. The 100% “positive” studies for SISs are unscientific at best, self-serving at worse. They increase public overdoses, public deaths, public use, needle litter, homelessness, crime.

    The arguments against SISs is in the comment section here under DonHonda:

    Google: East Bay Times 2017/09/07 supervised injection centers california weighs controversial law to fight opioid epidemic

  4. De-institutionalization started under the JFK Presidential administration. When Reagan was governor of California he signed a bipartisan bill (two Dems and one repub) that was advocated by leading mental health experts which advised that those suffering mental illness would do better by local treatment, being among family, friends and familiar surroundings for support. At the time, State mental institutions were liken to abuse as seen in “The Cuckoo’s Nest.” The ACLU also prompted this action due to its pending lawsuits for a Patients’ Bill of Rights where they can refuse treatment. This happened over forty years ago with both sides of the aisle kicking this can down the road. So, no one person or political party is solely responsible for what our communities are experiencing now.

    Recently, it has been found that California cannot account for the use nor efficacy of over $17 Billion earmarked for Mental Health services. This funding was garnered from Prop 63, The Millionaires’ Tax from over 12 years of its enactment.

  5. The “Safe” Injection Movement is sponsored by the Drug Policy Alliance, an advocacy group that works to decriminalize drugs and is funded largely by billionaire George Soros. The group has pushed, thus far unsuccessfully, for similar legislation in New York, Maryland, Massachusetts and Vermont.

    Here’s some examples of their thinking:


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