Photo of a panel hosted by the National Health Care for the Homeless Council
The National Health Care for the Homeless Council hosted a panel on May 21 at the Rayburn House Office Building to discuss substance abuse and homelessness. From left to right: Cynthia Kopec, Keith Belton, Tamisha McPherson, Courtney Pladsen, Bobby Watts. Photo courtesy of Keith Belton

After living in abandoned buildings for roughly 12 years while growing up, Keith Belton said he was homeless and started to engage is using addictive substances by age 13.

Belton, a client of the National Health Care for the Homeless Council from Chicago, spoke on a panel at a U.S. Senate office last month as a part of the organization’s annual conference in D.C. During the panel, Belton said he was the oldest of six children and his parents were alcoholics. He spent time in a juvenile detention, the foster care system and later as an adult, at least 12 penitentiaries.

“As soon as they put me in foster care, I was right back out there in the street,” Belton said. “They didn’t really have counseling back in those days. Got you in foster care, put you in school, and from there, it was you, and you just had to be in at a certain time.”

Belton said when he was in foster care he was learning how to survive because he didn’t anticipate being in foster care for long. Later, he began to use substances like alcohol and crack cocaine.

“All I knew was to get high or to get drunk,” Belton said in an interview with Street Sense Media.

Now, at age 55, it took both wanting help and finding a strong support network that met Belton with “open arms” to start on the road to recovery. After he was released from prison in 2012, he received medical assistance from Chicago Health Outreach and found a spiritual group – Willow Creek Church – that helped him move toward recovery.

“It completely changed my life,” Belton said. While people experiencing homelessness often struggle with substance abuse, he emphasized people don’t necessarily become homeless as a direct result of substance abuse. “That’s the myth that people have. When they see somebody who is homeless, the first thing they think is drugs and alcohol, but that’s not true.”

Photo of Keith Belton next to a poster about substance abuse

Keith Belton, a client of Health Care for the Homeless from Chicago, spoke on a panel last month about his lived experiences with homelessness and substance abuse. Photo courtesy of Keith Belton

Helping District Residents
The National Survey on Drug Use and Health from 2016 to 2017 found that 4 percent of District residents age 18 and older struggled with illicit drug use disorder. The survey estimated that less than 1 percent of people in the same age range struggled with pain reliever use disorder while 9 percent struggled with alcohol use disorder.

The number of fatal overdoses as a result of opioid use saw a 178 percent increase in the District between 2014 and 2016 and peaked in 2017 with 279 reported cases, according to a report from the Department of Behavioral Health. Officials from the department did not return multiple requests for comment.

Catherine Crosland, the medical director for homeless outreach development for Unity Health Care, said Unity Health Care has a network of clinics that prioritize meeting the needs of people experiencing homelessness, which include shelter-based clinics.

“We always believed in meeting our patients where they are, and we have partnered with overnight shelters, so that we can see patients, either as they’re coming in or leaving,” Crosland said.

For individuals who are struggling with substance abuse, having stable housing can help an individual prioritize treatment and stay sober. When someone has housing, the emotional and physical trauma of being homeless is removed from the picture, according to Crosland.

“In this work, we always say that housing is health care, and it’s in so many aspects of people’s lives,” she said.

Health groups in D.C. like Unity Health Care provide resources and treatment options for individuals struggling with substance abuse and the District government provides same-day service at its Assessment and Referral Center (ARC) to help match people to the best resources for them.

Whitman-Walker Health works to both provide treatment and support to people struggling with substance abuse and to de-stigmatize substance abuse disorders.

“These aren’t substance abusers. These are people with substance use disorders, and they’re people first, they’re not addicts,” said Adam Bloom, Whitman Walker’s behavioral health manager of substance use disorder treatment services.

The programs Bloom coordinates offer several resources for people struggling with substance abuse, including an abstinence-based outpatient program and a harm-reduction program for individuals who eventually want to give up a substance completely, but want to start by reducing how often they use it.

Whitman-Walker also offers medication-assisted treatment that is commonly used for patients who struggle with opioid abuse. But recovering from substance misuse isn’t only about prescribing medication. Individual therapy and peer support are integral components to recovery, Bloom said.

The health center does not offer methadone – a drug used to substitute substances like heroin – because it requires a specific license. Instead, Bloom said they utilize suboxone, a medication that can curb withdrawal symptoms and blocks the effects of opiates like heroin or prescription pain medication. The clinics are also able to prescribe naloxone – medication that blocks the effects of opioids – to patients struggling with substance abuse.

Cynthia Kopec, a client of the National Health Care for the Homeless Committee from Baltimore, said she went through medically assisted treatment, using suboxone, and went to a group meeting everyday. She said she hasn’t used the suboxone for eight months and hasn’t used any substances.

For some of Whitman-Walker’s services, patients can work with insurance navigators to find a payment plan that works best for the patient, Bloom said. The clinics can also assist individuals who are uninsured, and some patients may qualify for a sliding fee scale depending on their “poverty level.”

While Whitman-Walker does not provide housing, the health center refers patients in need to organizations like Friendship Place.

“Housing is a major concern – it’s a major concern all over the city,” Bloom said. “We establish the support with agencies that made [housing] their priority.”

Housing as health care
Bobby Watts, the CEO of the National Health Care for the Homeless Council, said there is an “extremely strong relationship” between poverty, health and homelessness.

“If you are poor, you’re more likely to be in poor health, you’re less likely to get the care that you need, which exacerbates the poor health,” he said during the panel for the council’s annual conference last month. “If your poor health and extreme poverty leads to losing your home or experiencing homelessness, then it makes it much more difficult to get treatment.”

Housing and substance abuse experts said having housing before attempting to seek treatment for individuals who are struggling with substance abuse increases the likelihood of success.

Mary Andres, an associate professor of clinical education at the University of Southern California, said housing helps an individual feel safe, and allows someone to be more receptive to support and care.

Andres said medical professionals often assume that medication is the first approach they should take when treating someone struggling with substance abuse. She said ensuring that someone has housing first can improve their sleeping habits and help them feel less anxious.

“A lot of times in our systems today, people treat it more expediently, like let’s just throw some meds at this and keep moving instead of really addressing the kind of woundedness that trauma causes,” she said.

Cynthia Kopec, the woman who found success using suboxone, started experiencing homelessness in 1993 and did not have stable housing until she found Health Care for the Homeless about 10 years ago.

Kopec remembers feeling abandoned at the age of four, when her mother left and took her two oldest brothers with her. After Kopec’s father remarried, she avoided her house as much as possible and started running with “the party crowd.”

She started using marijuana and alcohol at age 15 and said she met a man at age 30 who introduced her to heroin – a drug she had previously avoided. “I stuck out my arm and it was the best feeling I had ever had in my life,” Kopec said.

While she initially thought she would just “get high on the weekends,” she said she and her brother eventually became “fully-fledged heroin addicts.”

Health Care for the Homeless helped her secure housing, find medical treatment and join therapy programs. She called the people she met there nothing short of life savers.

“It was a reason to get out of bed, which I don’t always have,” Kopec said. She added that having a roof over her head, a bed and a shower has drastically improved her mental and physical health.

Suzanne Wenzel, the chair of the department of adult mental health and wellness at the University of Southern California, said people experiencing homelessness also experience a high level of “de-stabilization” in their lives because of things like losing their job, losing touch with family members and eviction.

Wenzel said an individual may turn to alcohol or another substance because of the “enormity of the trauma” they have or are currently experiencing. She said if an individual were using substances prior to becoming homeless, it becomes more difficult to stop or “slow down” use when they’re experiencing homelessness.

She added that in order to effectively address issues pertaining to substance abuse, an individual first needs stable housing. She said when someone is experiencing homelessness, they are first focused on where they are going to stay to be safe, where they are going to sleep, and where they are going to eat.

“If you have a place to shower every day, then you might be thinking more about, ‘now I can go to treatment, I don’t have to worry about where I’m going to sleep, I don’t have to worry about food, that’s taken care of, so I have a place to shower, I have some clothes, now I can start participating in other activities,’” she said.

Calling on health care professionals
Niranjan Karnik, the associate dean for community behavioral health at Rush Medical College in Chicago, said the “double stigma” surrounding people experiencing homelessness and struggling with substance abuse can make it difficult to access health care.

“People come in and a lot of health care professionals are somewhat dismissive of individuals who [misuse substances], and then they’re equally dismissive of individuals who are homeless,” Karnik said.

Not everyone who is struggling with substance abuse is necessarily ready for treatment. Karnik said health care professionals need to be cognizant of what an individual will be most receptive to and what will allow that individual to be most successful after they leave medical care.

“Good programs and providers will try to meet folks where they are, and be willing to help them to the extent that they’re willing to let them help,” he said, “Rather than insist that they try to meet some arbitrary threshold for engagement.”

Karnik said individuals who are experiencing homelessness, individuals who are struggling with substance abuse, and individuals who are both experiencing homelessness and struggling with substance abuse are all groups that end up needing the health care system more than average patients. They also have more contact with emergency rooms.

Even though people experiencing homelessness are in need of the most medical care, many housing and health care experts like Karnik, Crosland, and Bloom said a lack of training means a shortage of healthcare professionals who are properly equipped to treat individuals who are experiencing homelessness and struggling with substance abuse.

Items that are considered to be “social determinants of health,” such as housing and income, have only recently started being incorporated into medical school curricula, according to Karnik.

“Most health professional training programs were more focused on the biology and physiology of health,” he said. “[That] undoubtedly is important, but turns out not exclusively important.”

There has been a recent push from students in nursing and medical programs to provide health care to people experiencing homelessness. At his own university, Karnik said medical and nursing students have organized free clinics for homeless individuals and have sought specific training on how to best care for these individuals.

“We’re trying to meet that need,” Karnik said of medical faculty in the United States. “We’re trying to build that up, and I think that that’s amazing.”