Homelessness and Polysubstance Use: A Qualitative Study on Recovery and Treatment Access Solutions Around an Urban Library in Southern California, USA

Abstract

People experiencing homelessness face many obstacles and barriers when it comes to getting help for their substance use. Recently, there has been an increase in substance use and opioid overdoses at public libraries, which are easily accessible public places for those struggling with homelessness. We aimed to understand this population’s experience with recovery. This led to an exploration of the intersection of experiencing homelessness and substance use related problems and its impact on barriers for recovery, along with facilitators to treatment and recovery. From January-June 2019, researchers interviewed 22 library patrons experiencing homelessness and actively using substances at a Southern Californian library in a major metropolitan area. Data were coded and analyzed using a thematic analysis. Researchers independently coded text files for data analysis and discussed codes until consensus was reached. Library patrons who reported substance use were a mean age of 39 (range: 22-63); over half were white (59%) and male (59%); 77% reported currently sleeping on the street; 18% lived in shelters. Themes for barriers to recovery were experiencing withdrawal, access to resources, and coping with being homeless. Themes related to facilitators to treatment and recovery were Narcan access and overdose education, connectedness, and trauma recovery. People experiencing homelessness are hard to reach and those using substances pose even more vulnerabilities. Many patrons attribute their circumstances to their substance use and disconnectedness to resources and supports to quit. Further research is needed on best practices for multidisciplinary care coordination for this population.

Introduction

From 2018-2019, the US saw a 2.7% increase in the overall homeless population (UDHUD, 2019). California is home to six of the top ten cities with the largest homeless populations in the U.S. and saw a 16.4% increase in its homeless population in 2018-2019, which was more than the total increase of all other states combined (McCarthy, 2020; UDHUD, 2019). California is facing a homelessness crisis and it is critical to understand the needs of people experiencing homelessness.

About one-third of people experiencing homelessness experience alcohol and drug-related problems (NCH, 2017; Polcin, 2016; De Vet et al., 2013). Substance use (and the lack of needed resources) is in the top five causes of homelessness and in some cities is the third leading cause (NCH, 2017; 2019). Being homeless and using substances increases the risk of assault, getting infections, and contracting HIV or hepatitis C (Ickowicz et al., 2017). People experiencing homelessness across the U.S. overdose at higher rates than the general population (Bauer et al., 2016).

The connection between substance use and homelessness is difficult to parse out as substance use can be both a cause and a result of homelessness (Polcin, 2016). Therefore, it is important to approach this connection through the theory of intersectionality. We use intersectionality theory here to understand how homelessness and substance use can intersect with each other to create a unique lived experience, specifically in the area of recovery. The Recovery Science Research Collaborative (RSRC) defines recovery as an “individualized, intentional, dynamic, and relational process involving sustained efforts to improve wellness” (Ashford et al., 2019; 183).

The theory of intersectionality was born out of Critical Race Theory and Black feminism by Crenshaw (1989) and has expanded to include power dynamics, political systems, and social identities, to show the complexity of the lived experience of individuals (Carbado et al., 2013). Intersectionality has grown to include homelessness as a power dynamic that produces power imbalances and discrimination (Lurie et al., 2015; Giannini, 2017). Intersectionality is a theory of social change that inspires social movements and advocacy for vulnerable and disadvantaged communities (Carbado, et al., 2013).

Homelessness and substance use have created a treatment conundrum that can best be examined through structural intersectionality (Crenshaw, 1991; Narendorf, 2017; AAC, 2020). About 60-70% of people experiencing homelessness do not have insurance and treatment, such as detox, inpatient or outpatient rehabilitation, therapy, or medication, can cost anywhere from $1,000-$60,000 (Baggett et al., 2010; Juergens, 2020). Maintaining recovery from substance use is more difficult when unstably housed and resources that work on both housing and substance use are rare (Polcin, 2016). Treatment cannot just address substance use, but should also address housing insecurity and other vulnerabilities that create barriers to recovery. Some individuals who are homeless and enter detoxification or treatment quickly relapse, making it feel as though they are destined to fail (Kertesz et al., 2003). Additionally, resuming use after a period of abstinence or detoxification increases the risk of overdose (WHO, 2020).

With increases in the homeless population, and the looming opioid crisis, a need to change the treatment landscape has become increasingly visible. In the U.S., public libraries have been taking on this task to better help their patrons struggling with homelessness and substance use. Libraries are one of the last remaining free spaces that welcomes everyone, becoming an epicenter of refuge for people experiencing homelessness. With this, many libraries have also seen an increase in substance use within their facilities. Libraries in large cities have all seen overdoses within their facilities, which has caused an urgency for some to expand their services to include Narcan/Naloxone training for staff and bringing in a social worker to better meet the needs of patrons (Miguel, 2017; PBS, 2015). Public libraries offer a unique place to reach this population and potentially serve as a main hub for resources and first point of contact.

In this study, we describe results of a qualitative study conducted at a large public library with people experiencing homelessness and substance use related problems. We aimed to understand this population’s experience with recovery. This led to an exploration of the intersection of homelessness and substance use related problems and its compounded impact on barriers for recovery, along with facilitators to treatment and recovery. To our knowledge, we are one of the first studies to look at the intersection of homelessness and substance use as intersecting identities that affect access to recovery.

Methods

Sampling

This qualitative study analyzes data from a larger study that focused on homelessness at an urban library in a major metropolitan area in Southern California, the original aim of which was to find out how libraries could further serve those facing homelessness. Upon conducting interviews, we noticed a large gap in understanding how people experienced homelessness and substance use, particularly the barriers and facilitators to engaging in treatment and, moreover, sustaining recovery. A purposeful homogenous sampling strategy was used to gather participants of a certain subgroup that could provide deep, context-rich information and knowledge about their experiences (Palinkas et al., 2015; Ravitch & Carl, 2016). Participants were recruited at the library through fliers, announcements at the library by the library staff about the study and how to participate, and a sign-up sheet at the library’s reference desk. Inclusion criteria consisted of people over 18 years old, currently identifying as unstably housed or homeless. For this sub-study, those who actively used substances were included in the analysis. Members of the research team with lived substance use recovery experiences also conducted targeted outreach to library patrons actively using opioids on the streets outside the library. This posed an opportunity for reflexivity on how experience with substance use recovery may affect the interviews.

Data Collection

The study used a qualitative approach. Data was collected through the use of in-depth interviews, focus groups, and a brief socio-demographic survey. Data were collected from January 2019-June 2019. Interviews were conducted by the first and second authors, along with trained social work and public administration graduate students from San Diego State University in private rooms within the library or in the surrounding area where participants felt most comfortable. Focus groups took place in a private conference room at the library. Individual interviews took one to two hours and the focus groups lasted 90 minutes to two hours. Interviews and focus groups were audio-recorded at the consent of the participants. One participant declined to be recorded due to wishes to protect their privacy and one participant was not recorded because it was conducted over the phone.

Participants were interviewed using a semi-structured interview guide that covered, among others, the following topics of focus for this study: how often patrons witnessed or heard about overdoses occurring at the library, barriers to addressing problems associated with overdoses or drug use, and suggestions about how drug use/overdose can be better addressed at the library. In addition, a focus group with opioid and polysubstance users sought to understand the opioid overdose crisis at and around the library better. The themes that emerged were recovery and treatment barriers and facilitators.

Data Analysis

Interviews were transcribed verbatim and reviewed within seven days by the Principal Investigator (second author), using an iterative approach to qualitative inquiry that informed subsequent interviews. This study used thematic analysis driven by a qualitative approach. (Ravitch & Carl, 2016; Boyatzis, 1998). The interviewers engaged in conversations over their positionality as university researchers and how their experiences differed from or resembled the participants’ experiences of homelessness, severe substance use, or socioeconomic status, influencing both their interpretations of the data and the reaction of participants toward the researchers.

Data analysis occurred immediately and iteratively, allowing the researchers to revise and refine data instruments and the research focus (Twining et al., 2017). Two researchers independently coded the transcripts and discussed codes and themes until consensus was reached for the codes. Transcripts were then coded again using the agreed upon codes. To enhance the trustworthiness of the data, method and data triangulation were used by conducting both individual interviews and focus groups with different participants and at different times. The authors also presented the findings to a group of participants for member checking, where participants were able to provide feedback.

Ethical Consideration

This study was approved by the San Diego State University ethical review board. Participants provided written informed consent and researchers explained that they could withdraw from the study at any time and refuse to answer questions. Due to the high vulnerability of this population, participants received a list of resources and contact information for the PI and IRB.

Participants were given $20 in Metropolitan Transportation Authority Day Passes for participating, regardless if they were able to finish the interview or focus group. Those who participated in a focus group were also given a light breakfast and refreshments.

Findings

For this study, 22 participants reported experiencing both homelessness and substance use, with 15 of the participants being individually interviewed and 7 participating in a focus group specifically for people experiencing homelessness and using substances. Although the types of substance use were not collected through the brief socio-demographic surveys, 14 participants reported being polysubstance users, 6 reported being opioid users, one reported using cannabis and alcohol only, and one participant reported only using alcohol.

As shown in Table 1, over half of the participants were male and White. Participants ranged in age from 22-63 (mean=39 years, SD=11.8). Half of the participants (50%) reported a disability, ranging from physical, mental health, and educational disabilities, and 77% were sleeping on the street. Themes that emerged about barriers to treatment and recovery were substance use withdrawal, access to resources, and coping with homelessness. Themes related to facilitators to treatment and recovery, were Narcan access and overdose education, connectedness, and trauma recovery.

Table 1.

Participant Characteristics (N=22)

N (%), Range, or M ± SD
Gender
Male	13 (59%)
Female	9 (41%)
Age
Range	22-63
M ± SD	39±11.8
Race
White/Caucasian	13 (59%)
African American/Black	2 (9%)
African American/Native American	1 (4.5%)
Hispanic/Latino	2 (9%)
Hispanic-White	3 (14%)
Hispanic-Native American	1 (4.5%)
Current Housing
Streets/Homeless	17 (77%)
Staying with a friend	1 (5%)
Shelter	4 (18%)
Veteran
Yes	4 (18%)
No	18 (82%)
Disability
Yes	11 (50%)
No	11 (50%)

Barriers to Recovery

Experiencing Withdrawal

If I don’t take care of my heroin addiction in the morning…I get sick and then it’s hard for me to do anything else throughout the day. So, I try to take care of that first. (Male participant, 23, opioid user, individual interview).

Participants (N=18) discussed how they mainly continued using to prevent withdrawal symptoms, especially for those who used opioids like heroin. Participants discussed how being homeless was a “full-time job” consisting of, but not limited to, waking up early, moving their belongings, and finding access to sanitation centers, restrooms, food, and places to charge their electronics. Engaging in their substance use became more about maintenance and being able to function throughout the day, rather than for the enjoyment or pleasure they had experienced in the beginning of their use. Keeping themselves from withdrawing was also added work for them in regards to finding substances and being able to use them in a safe place.

Those who were able to access resources, such as detox centers or medication for opioid use disorders (MOUD), continued to face barriers in using them. Going through withdrawal is a difficult, sometimes painful, process and although some participants reported trying to get through it to be sober, they often broke down after a couple of days due to the symptoms. None of the treatment centers in the area provided a medically assisted detox and if they wanted to enter treatment, they had to have already detoxed. This is often a barrier as they wanted to relieve their pain from withdrawal and felt that the only way to do this was through using. Many of the participants reported frustration with this lack of care when they would go to the hospital to detox:

[I] didn’t make it past day three at any of them because they don’t give you any kind of help. They [are] just like sort of like, “Okay, well, you can lay in bed for three days and then that’s it. You’ve got to go to group for the other seven days. (Male participant, opioid user, focus group)

During the focus group, participants described how clinics provided Suboxone (a MOUD), to take to the hospital or to even use at home, to help them detox comfortably. However, with Suboxone, a certain point of withdrawal must be met before starting, thus perpetuating the difficulty of getting to that point to start treatment. Furthermore, many lived on the street, not even in a shelter, reducing any potential for comfort.

Access to Resources

Lack of insurance, being unaware of low barrier treatment options, having limited options due to insurance, cost, and long waitlists were mentioned as leading to a lack of treatment access. Those who were able to get on waitlists found it difficult to maintain their recovery due to not having a stable environment or accountability. A 24-year-old male participant who used opioids recounted how he had gotten into a sober living home, but was unable to move in due to having a positive urine screen. Similarly, a 47-year-old veteran who used opioids started using again while on a waitlist for VA housing. Without the stable housing and structure that the sober living home or the VA housing could provide, they both turned back to the “comfort and stability” of using. Those who made gains in their recovery were met with continued hurdles that made it difficult to continue with their progress, showcasing the need for more urgent access to services to sustain their efforts made toward recovery.

Participants (N=12) stated being worried about accessing certain resources, such as Narcan, a medication used to reverse opioid overdoses, due to the unnecessary involvement of emergency services and drawing attention to themselves. There was notable disdain toward Narcan due to it ruining one’s high or causing immediate withdrawal.

Coping with Being Homeless

All participants used substances to cope with homelessness and living on the street. The majority of participants lived on the street (77%), which comes with many risks such as physical or sexual violence and having belongings stolen. These potential threats created a lack of safety and comfort for participants. To cope, some used stimulants, such as methamphetamines, to keep them up to better protect themselves. Others used substances to help them slip into sleep and lose sense of their surroundings:

When I was sleeping on the streets before I wouldn’t be able to sleep because I would be uncomfortable and I would just pass out from exhaustion after four days. I was so young I couldn’t legally drink yet, but if I could get alcohol or like Xanax or whatever the fuck, then I could pass out. (Male participant, 22, polysubstance user, individual interview).

Substance use sometimes became a necessity to survive by making the moment and the situation bearable. Participants (N=11) mentioned that using substances helped make it easier to deal with being homeless, usually by numbing one’s feelings or helping one escape from their reality:

…I mean, it kinda makes it easier to deal with…A lot of us, we resorted to the drugs because…it’s coping with the fact that I’m out here. I gotta deal with figuring out where I’m a sleep and if it’s gonna be safe and if not, can I make it safe? (Female participant, 26, polysubstance user, individual interview).

Facilitators to Treatment and Recovery

Narcan Access and Overdose Education

Participants (N=9) mentioned how access to Narcan/Naloxone, a medication that can reverse opioid overdoses, has been helpful, but could be more available. Narcan is a harm reduction tool that helped patrons feel more in control and able to take care of themselves and others. Narcan is available at most pharmacies, depending on which state one lives in, but varies in cost. Every participant had either witnessed or experienced overdosing. All 7 participants in the focus group agreed overdoses occurred weekly to sometimes daily. Four participants reported receiving Narcan from a local needle exchange and expressing how this was a helpful resource. Participants (N=3) mentioned how the library shouldn’t be responsible for carrying Narcan and administering it, while (N=14) explicitly suggested having Narcan available within the library in case of emergencies, recognizing that there will always be a need for it:

I think it would be [good] to have a Narcan…I think if it was in the bathroom, especially in the libraries because guess what, we are always going to be doing heroin. (Male participant, 25, opioid user, focus group).

Raising awareness of overdosing in regards to how to detect it and how to intervene was also a common topic. Some participants (N=3) reported skepticism on the necessity of Narcan and felt that they had other methods that could help with overdoses and had less withdrawal effects. These differing attitudes and the fear of utilizing emergency services for help with overdoses showed a need for overdose education.

Connectedness

Although participants were connected to each other, e.g. those in the focus group, or to select services outside of the library, their knowledge and connections to low barrier substance use treatment options were limited. The library is a central location that could be used as a hub for resource connections that increases access to knowledge of services, especially in regards to substance use and housing. Accessing resources can be time consuming, confusing, and daunting when their resources were limited, especially time. The participants wanted someone who would “walk with you and take you there and help you kind of go through this process” (Female participant, 51, opioid user, focus group). Having someone who knows the ins and outs of housing and substance use resources could help someone feel less alone and overwhelmed.

Libraries are rich with resources, such as emergency housing, substance use, and mental health referrals, but patrons were often unaware of them. Oftentimes, connecting to these resources can fall onto librarians and it was recognized that this was not their job to act as social workers and case managers. Participants (N=22) agreed that having a social service professional who can navigate services at the library would be beneficial in regards to helping them connect to resources, especially MOUD.

Trauma Recovery

Experiencing homelessness is traumatic and isolating, and it was common for our participants to mention past traumatic events and experiences. Isolation was also used as a technique to cope with being homeless, whether it was to avoid being put into violent situations, being pulled into dealing drugs, or to avoid complacency and to keep their pride. Most participants (N=18) wanted someone to talk to, such as a therapist, about their experiences in a private setting.

I feel like that [therapy] would really help a lot of people more than a 12 step because everyone has that story of why they’re in that situation, everyone has a lot of you know, a lot of people have issues, it’s like, wow, you’d think you have a problems before you’re homeless, you’re gonna come out of that with ten times as many mental issues, you know? (Male participant, 22, polysubstance user, individual interview).

Peer related support was also seen as a resource that could aid in recovery for participants. The intersection of their identities as experiencing homelessness and using substances made it difficult to connect with others who may identify with only one of these identities, or none. Experiencing homelessness can sometimes lead to a loss of hope and dignity, making it difficult to connect with professionals who have not experienced it first-hand. Being able to see someone at the library who had gone through similar experiences as them and show that recovery and getting out of homelessness was possible was an important aspect of professional support. It was even more important that the person had experienced both homelessness and substance use related problems:

But when you go to somebody who absolutely has used and been in that situation and understands the withdraws and the meaning of the withdraws and the severity of the withdraws and what an actual withdraw feels like. I would be more open to talk to one of them… to actually have that physical experience to me is very important because I have more to relate to you because it gives me an option, okay well you overcome it and you been sober for how long?… But to sit here and say okay what kept you strong? What is keeping you strong? What’s keeping you going? What’s keeping you from not using? I would rather listen to that you know because they are like still fighting every single day with substance abuse--alcoholism on a daily basis. Because it’s not something that goes away. (Female participant, methamphetamine user, focus group)

I think that you gotta have somebody that has been through it…Somebody that has hit rock bottom and has now worked through steps and done everything and show that, hey you can come back. Somewhere along the line here you lose your confidence. (Male participant, 47, opioid user, individual interview).

Discussion

This current study used qualitative methods of semi-structured interviews and focus groups to understand the nuances of the intersectionality of experiencing homelessness and using substances. Barriers to recovery emerged as major themes: experiencing substance use withdrawal, barriers to accessing resources, coping with homelessness. Facilitators to treatment and recovery were: increased Narcan access and overdose education, connection to resources, and having someone to talk to (peers or therapists) to overcome trauma and isolation.

Withdrawal was the most common barrier to recovery for participants. Experiencing homelessness made it increasingly difficult to get through withdrawal, detoxification, and work towards recovery. Withdrawal symptoms can be debilitating and there was a notable lack of resources available to help with withdrawal. Lack of resources is highly common with both homeless populations and people who use substances and when these identities intersect, accessing resources becomes more difficult (Wusinich et al., 2019). If services are available, people encounter barriers such as long wait lists, lack of transportation, and not having required documents such as an ID (NCH, 2009). Our participants who entered treatment were unable to engage in medically assisted detoxification, often leaving early due to the withdrawal symptoms. Even those who were able to access MOUD found it difficult to reach the withdrawal point necessary to start the medication. Thus, access to detox centers that addressed withdrawal symptoms was one of the largest barriers to starting recovery for our participants.

Although medically assisted detox was not widely available for participants, most of them expressed wanting to go through treatment. However, being able to access treatment was another barrier to recovery, mainly due to structural intersectionality. Participants mentioned how their insurance and lack of money limits where they can go for services, especially detox and treatment centers, and whether they can afford MOUD. Substance use treatment, whether it is MOUD, inpatient, or outpatient services, can be costly and some insurances may not be accepted or provide full coverage (NIH, 2018). Services that are available and accessible are usually lacking in the resources that are needed, specifically the integration of treatment for substance use, services for mental health, and stable housing (Polcin, 2016).

Those without housing and using substances may feel that meeting their more basic needs, such as a place to stay and food, take precedence over getting help for their substance use (NCH, 2009). Substance use and homelessness cannot be treated separately due to the intersecting nature of the two experiences. Participants felt that they couldn’t address their substance use without addressing their housing, but housing was difficult to access for those with substance use related problems. Substance use and homelessness should be addressed simultaneously to better achieve recovery and stability for this population (Polcin, 2016; NCH, 2009). Housing first initiatives have been effective harm reduction tools in helping those who are homeless and struggling with substance use (Watson et al., 2017). Shelters usually have strict policies against substance use and are not often viable options for those who are homeless and using substances. Housing First Initiatives usually do not require one to be sober and they offer a safe place for someone to transition to post-treatment rather than being put back on the street (Polcin 2016; Watson et al., 2017).

Participants in our study reported wanting to have Narcan available to help people who are overdosing, and some suggested it be available within the library. Some libraries across the country have been training their staff on how to use Narcan (Rehagen, 2020; Philbin et al., 2019). The California State Health Officer has allowed for community organizations not working with a physician to be able to obtain naloxone for use, such as libraries, but not all libraries in California carry naloxone on their premises or make it widely known (California State Library, 2020). Many libraries have opened their doors to social services and other organizations that are more equipped to help meet the needs of their patrons (Wahler et al., 2019; Whiteman et al., 2018). Public libraries can be resources for public health and well-being and offer programs that are accessible to everyone, especially the most vulnerable (Morgan et al., 2016).

Substances are often used as maladaptive coping skills, which participants agreed with and would use as a way to cope (NCH, 2017). Past studies have suggested the social environment plays a role in substance use as it is a way of finding acceptance within the homeless community, which in turn could reduce isolation (Didenko & Pankratz, 2007). Participants reported isolating as a way of coping or avoiding harm, but felt that their isolation and hopelessness could be lessened if there was someone in the library, like a peer navigator, who had similar intersecting identities and had gone through similar experiences. A peer navigator could also be someone who provides standard case management for patrons, which has been found to be more effective in reducing use than only referring them to community services (De Vet et al., 2013).

Access to therapy was a common recommendation and facilitator to recovery from participants and seen as a way to help them learn new coping skills. There is a lack of access to therapeutic services and it is made more difficult depending on one’s insurance, or lack thereof. The participants felt that the library could offer such services and that they would be more likely to utilize them. Libraries across the country have been shifting their services to meet the unique needs of their community. Some, like the San Francisco Public Library, have hired social workers that provide therapy, case management, and help connect patrons to resources (Rehagen, 2020; Wahler et al., 2019).

Limitations

A limitation of this study was in our sampling methods and recruitment. Patrons participated only if they were able to respond to a flyer, sign up for an interview or focus group and follow through, or agree to join on the spot. Some patrons like those who were so gravely mentally disabled that they could not talk to anyone or those with more severe substance use may not have been able to participate. One patron who had taken fentanyl before the focus group fell asleep after speaking his mind, but he was lucid when awake or awoken. Another limitation was not explicitly asking for the type of substance being used by participants. The larger study did not focus specifically on individual substance use disclosure, but as this information came up in interviews, it was later asked more directly during the iterative research process.

This study has further implications for future research and policy. These results illustrate a need for interventions and access to low-barrier resources for this population. This study enabled us to hear first-hand what participants thought was most important for their recovery, rather than the researchers deciding what would be best for them.

Libraries across the country have started implementing services to combat the opioid crisis such as hiring social workers, increasing resource availability of Narcan and drug disposal kits, developing partnerships to better coordinate services, and raising awareness to end stigma toward substance use disorders (Allen et al., 2019).

Conclusion

The intersection of homelessness and substance use creates a complex experience that can make it more difficult for someone to engage in recovery. Our findings have implications for future directions of interventions that can be implemented to help this population achieve their recovery and personal goals. Further research is needed on best practices for multidisciplinary care coordination for this population. As previously mentioned, a strong initiative that has been used with people experiencing homelessness and substance use related problems is Housing-First Initiatives. Many of the participants mentioned how they used substances to cope with being homeless, whether it was to help with sleeping on the street or staying awake for safety, or coping with their reality. Housing-First initiatives have been used for people with substance use problems or serious mental illness in Canada where they have found a reduction in use and an improvement in their health status (Gaetz et al., 2013). Housing first initiatives may be an effective way to reduce substance use in this population. The addition of social workers and social services into libraries may be a new way to better help link people to resources and care, such as medically assisted therapy and housing. Due to their easy access and trust from the public, public libraries provide an opportunity to increase resources for substance-using homeless populations.

What is known about this topic:

• People experiencing homelessness have substance use problems at higher rates than the general public

• People facing homelessness experience many barriers to treatment access

• Experiencing homelessness and using substances puts one at an increased risk of contracting infectious diseases and experiencing violence

What this paper adds:

• Persons experiencing homelessness and polysubstance use around a major metropolitan library during an escalating opioid epidemic were found to have specific nuanced barriers to their substance use recovery, e.g., a lack of connectedness, especially to services and treatment, than the general population.

• Fears of withdrawal from substances is one of the main barriers to accessing substance use recovery treatment for those who were homeless.

• Participants expressed a need for a better transition to resources (e.g. MOUD) such as someone to walk them through the process rather than giving referrals or information.