For participants with regular drinking, we asked participants how many drinks they consumed in a typical day using a question modified from NSHAPC.If participants drank 5 or more equivalents in a day, we classified this as binge drinking.We asked participants to report if they had ever received treatment for use of alcohol or illicit substances. Participants self-reported their health status,which we dichotomized as fair or poor versus good, very good, or excellent. Based on the National Health and Nutrition Examination Survey , we asked participants to report whether a health care provider had told them that they had diabetes, emphysema or chronic obstructive pulmonary disease , asthma, stroke, coronary artery disease or a heart attack, congestive heart failure, cirrhosis, or cancer.We asked participants whether they had tested positive for HIV infection or had ever been told they had AIDS. To assess functional status, we asked participants if they had difficulty completing individual ADLs because of a physical, mental, emotional, or memory problem using the questionnaire developed by Katz.Using logistic regression, we assessed bivariate relationships between independent variables and the two dependent variables, moderate or greater severity alcohol symptoms , and moderate or greater severity symptoms for any illicit substance . We dichotomized race to African American versus non-African American because there were no significant differences among white, Asian, Latino, and other participants in the odds of substance use outcomes when only these participants were included. To construct multivariate models,cannabis growing equipment we selected independent variables based on bivariate relationships with p≤0.20 and performed backward stepwise elimination, retaining independent variables with multivariate p≤0.05.
As a sensitivity analysis, we created an alternate model including only participants with active illicit drug use in the previous six months to examine if participants who were scored with moderate severity symptoms for the ASSIST based on significant cravings alone differed significantly from those who were actively using.HOPE HOME participants had a median age of 58 years . Over three-quarters, 77.1%, were male, and 79.1% African American; 21.7% were veterans. Approximately a third had PTSD symptoms and 38.3% had major depressive symptoms; 22.3% had both depressive and PTSD symptoms.Nearly half experienced their first episode of homelessness after they turned 50 years old.Almost a third had ever been suspended or expelled from school.About a third experienced physical abuse as a child, while 13.2% experienced sexual abuse as a child. Approximately half experienced physical abuse as an adult, while 13.2% experienced sexual abuse as an adult. The majority, 55.7%, reported fair or poor health status, and 38.9% reported they were dependent in one or more ADLs. Almost two-thirds of our sample, 63.1% had used an illicit substance in the last 6 months, and 64.6% had moderate or greater severity symptoms for at least one illicit drug, with 14.5% reporting severe symptoms . Almost half, 49.2% had used alcohol in the last 6 months, while 25.8% had moderate or greater severity alcohol use, with 14.6% reporting severe symptoms. Approximately a tenth of HOPE HOME participants reported binge drinking and 60% drank at least three times a week to get drunk at some point in their life. For illicit drugs, the drugs most commonly used in the last 6 months included cannabis with 48.0%, cocaine with 37.7%, opioids with 7.4%, and amphetamines with 7.1%. The three most commonly reported drugs with moderate or greater severity symptoms were cocaine,cannabis,and opioids . For participants with ASSIST-defined moderate or higher severity illicit drug symptoms, 91.6% had used an illicit substance in the last six months. For cannabis, 92.7% of participants with moderate or higher severity symptoms had used that specific substance in the last 6 months: 79.5% for cocaine, 67.8% for opioids, and 67.9% for amphetamines. All participants with high severity illicit drug use, and all participants with moderate or greater severity alcohol use had used in the last 6 months. A smaller proportion reported injecting drugs in the last 6 months.
Almost a third reported moderate or greater severity symptoms for more than one illicit substance; 21.4% reported moderate or greater severity symptoms for both cannabis and cocaine. Less than a tenth of the sample used illicit non-cannabis drugs regularly, three times a week or more, prior to age 18, while 36.6% used cannabis regularly and 15.1% used alcohol regularly before age 18. 1.3.3 Multivariate Analysis In multivariate models , having been expelled or suspended from school was associated with moderate or greater severity illicit drug symptoms , as were having a history of psychiatric hospitalization,and having one’s first episode of adult homelessness prior to the age of 50 . In a multivariate model examining factors associated with moderate or greater severity alcohol symptoms, expulsion/suspension from school , male sex and the presence of major depressive symptoms were associated. Neither age, race/ethnicity, veteran status, education, PTSD symptoms, nor a history of sexual or physical abuse were associated in either model. An alternate modeling strategy that restricted moderate or greater severity illicit drug symptoms to those with active current use, as opposed to including all who met moderate severity ASSIST scores, changed p-values less than 10%. In the alternate model history of psychiatric hospitalization was no longer significant. In a sample of homeless adults aged 50 and older, we found high prevalence of substance use, with 14.5% reporting severe illicit substance symptoms compared to 6% of a sample of homeless-experienced adults of all ages engaged in primary care.When comparing current illicit substance use of HOPE HOME participants to a community-based sample that included all adults from 1996, NSHAPC, we find higher current illicit substance use, 63.1% vs. 23%.Moderate or greater severity alcohol use was high, with 25.6% of patients reporting moderate or greater severity alcohol use compared to 4.6% of adults of all ages in a VA primary care clinic.When comparing current binge drinking of HOPE HOME participants to NSHAPC, 10.3% of HOPE HOME participants reported binge drinking compared to 19% of NSHAPC participants.Approximately three-fifths of both HOPE HOME participants, and NSHAPC participants drank at least three times a week to get drunk at some point in their life.Participants were medically complex. They reported a high prevalence of chronic conditions, ADL dependencies,cannabis grow racks and poor health status, and therefore had an elevated risk of harm from substance use.
Consistent with prior research, we found that psychiatric hospitalization and depression were associated with substance use.The association between psychiatric hospitalization and illicit substance use is likely bidirectional.Individuals with SUDs may exhibit severe behavioral symptoms such as hallucinations, disorganization, or aggressive behavior that may lead to psychiatric hospitalization.The association of depressive symptoms with moderate or greater severity alcohol symptoms, and psychiatric hospitalization with moderate or greater severity illicit drug symptoms, has clinical relevance to programs designed to address substance use in older adults. An ideal program would integrate treatment of mental health conditions with substance use disorders. There are limited numbers of geriatric psychiatrists, particularly those who work in urban under served populations.They may be ill-equipped to accommodate an older adult with multiple medical comorbidities and functional dependencies. Young adult life experiences prior to age 50, specifically onset of homelessness prior to age 50, and a history of expulsion or suspension from school, were associated with participants’ later substance use. Substance use may be an important cause of homelessness for younger adults.In contrast, other causes such as medical illness, financial hardship, or loss of social support may be more likely to cause homelessness for adults who become homeless later in life.The finding that at-risk illicit drug use is associated with a history of homelessness earlier in life is germane to public health programs seeking to prevent incident homelessness in younger adults. The only factor associated with both moderate or greater alcohol and illicit substance symptoms was a history of expulsion or suspension from school. Suspension and expulsion could be a marker of early substance use.
Prior research has shown that students who attend schools that suspended or expelled for drug infractions at high rates, while controlling for substance use prevalence, were more likely to have higher prevalence of substance use at one-year follow-up.Unintended negative consequences of suspension and expulsion include disengagement from school, loss of social support, and increased risk of arrest.Adults who become homeless earlier in life tend to have more early life adverse experiences such as mental health, imprisonment, and substance use.44 It is possible that the association between suspension or expulsion from school and greater severity illicit drug and alcohol use is a reflection of the impact of early life experiences on the risk of developing risky substance use later in life. When we compare HOPE HOME participants’ illicit drug use prevalence to NSHAPC, we find higher prevalence of substance use for HOPE HOME participants, despite the HOPE HOME participants reporting on a shorter duration of time and all being age 50 and older . Our primary explanation is that adults born in the baby boom have different substance use patterns than those born in prior generations. This is supported by literature in the general population.45 However, we cannot exclude the possibility that local differences in substance use prevalence could contribute to the observed difference. Other alternative explanations are less likely. A higher percentage of HOPE HOME participants who were age 50 and older had been homeless for a year or more compared to NSHAPC adults of all ages, 67.1% vs. 55%. However, this is unlikely to account for the difference. Other data has shown that, regardless of substance use behaviors, there is a trend in increasing duration of homelessness in the United States.15 Another alternative explanation is that HOPE HOME included individuals who did not access or had limited contact with homeless services, and therefore had less access to treatment interventions. However, only 1.6% of HOPE HOME participants did not access any services in the last six months, meaning that this difference alone is unlikely to contribute to the differences we found in substance use prevalence. In spite of these possible alternate explanations, we believe that the magnitude of difference suggests that illicit substance use is higher in older homeless adults than was noted twenty years ago. The older homeless population now is made up of people born in the baby boom. Contemporary older homeless participants experienced the crack cocaine epidemic in their young adult lives. Data from the general population suggests that individuals born in the baby boom have a higher prevalence of substance use than those born in previous decades. We found lower prevalence of binge-drinking in HOPE HOME participants. The younger age distribution of NSHAPC participants may be responsible for the observed differences in binge drinking, as binge drinkers are less likely to survive to late adulthood.46 Our study has several limitations. We were not able to account for clustering of our sample among some sites as we did not have accurate counts of numbers of unique visitors at each site. We do not consider recruitment sites to be clusters because of the mobility of the population and the tendency of participants to frequent multiple venues of recruitment. Given that our sample was predominantly African American, and had a narrow age range, we were not powered to examine use by race and ethnicity, or age. A potential concern with usage of the ASSIST is that some participants were classified as having moderate severity illicit drug symptoms despite not having used that particular substance in the last 6 months, i.e. participants with remote use but active cravings for an illicit substance. The ASSIST is designed to identify patients at risk of harm from substance use and in most need of intervention. We chose to include these participants in our modelling strategy as this ASSIST score is clinically relevant. . However, one variable, history of psychiatric hospitalization, was no longer significant when excluding those without active use. With high prevalence of substance use in older homeless adults, there is increasing evidence of negative effects of substance use. When the median age of the homeless population was younger, the majority of substance use-related mortality in the homeless population occurred in younger homeless adults.However, between 2003 and 2008, older homeless adults’ mortality attributed to illicit drugs approached that of younger adults and older homeless adults’ mortality attributed to alcohol exceeded that of younger adults.