Social Policy in Ontario

Recent reports indicate an alarming increase in the number of people in Toronto who are dying of opioid overdoses. Other reports indicate people who are homeless are dying at high rates this year.

These observations may be linked — and understanding how homelessness and drug use are linked may be the key to developing solutions that can keep people alive.

We think there are three common misconceptions about homelessness and substance use that may be linked to tragic outcomes for some of Toronto’s most vulnerable people.

First, many people assume that all people who are homeless live socially isolated lives. However, people who are homeless, throughout history, have at times organized themselves into highly structured support environments.

The second misconception is that removing people from environments where substance use occurs will improve their health and chance for sobriety. While that may be true for many people, it may be dangerous for some people who use drug or alcohol and have experienced long-term homelessness.

For people who inject drugs, friends and peers may represent informal harm reduction networks and may assist with securing drugs of known composition or quality and supplying sterile needles and other supplies. Having a peer support network can also be important for helping people with “bad trips” and for managing overdoses.

The third misconception is that housing a person who is homeless will automatically improve their health and well-being. Housing helps many people and is an essential intervention for most. For others, the transition from homelessness to housing can be complex and challenging, especially for people who use drugs.

The Toronto Community Addiction Team (TCAT) is an intensive case management program at St. Stephen’s Community House for people with complex substance use issues who frequently use emergency services. While the large majority of people did better after being housed, a few continued to use emergency department services, experienced deteriorating health, and were facing evictions, despite everyone’s best efforts.

TCAT responded by developing a custom designed housing program for 10 such people. Tragically, all 10 died while waiting for the new program. Most died while they were still young, with several in their 30s. Many died in their homes.

Together, these misconceptions and observations suggest that for people who have a long history of being homeless and using drugs, the complex interaction of substance use, social network disruption, isolation, and dislocation from usual neighbourhoods may have negative health effects and can occasionally be tragic.

Three west-end Toronto agencies that serve people who are homeless began to systematically record the circumstances around the death of clients. Over half of the people who died were housed, many in supportive housing. They also had access to primary care, case management and other supports but none of these were effective in averting death.

An Indigenous man in his mid-30s opens the door to his brand new subsidized housing unit, walks to the balcony and leaps to his death.

His brother, not much older, dies in a shelter from complications related to heavy alcohol use after several failed attempts at living alone.

Another young Indigenous man asphyxiates on vomit, alone in his housing, a week after complaining to his social worker that all of his friends had been barred from his building.

We need to do some things differently.

First, we should move away from a standard housing policy toward a person-centered approach that responds to individuals’ needs. We should recognize that people who are homeless often have networks; someone may not have a home but may still have a home neighbourhood. Housing models should consider such supports when housing is being assigned, particularly in large cities, like Toronto, where people may be housed far away from their home neighbourhoods.

Second, we need to integrate harm reduction approaches into housing policies. Strict rules about abstinence and limits on the number or type of visitors may be dangerous.

Third, we need more research to understand the risks associated with transitioning from being homeless to being housed and how to ameliorate those risks.

We are part of an innovative collaboration of people who work in community agencies, public health specialists, clinicians, and academics that has come together to talk with each other and with people who have an experience of homelessness. We believe we need to start with community experiences to develop effective policies.

Ahmed Bayoumi is a physician and scientist at the Centre for Urban Health Solutions at St. Michael’s Hospital. Lorie Steer is director of Housing and Homeless Services at St. Stephen’s Community House.

https://www.thestar.com/opinion/commentary/2017/05/31/common-misconceptions-about-homelessness.html