Leveraging the Affordable Housing Sector to Respond to the Opioid Crisis

Housing is a crucial determinant of health and of particular salience for people living with a substance use disorder (SUD). Lack of affordable housing exacerbates vulnerability to risky substance use, mental health stress, risk of recurrence of use if in recovery from SUD, and environments that are difficult to keep safe and clean, as has become especially clear during the coronavirus disease 2019 (COVID-19) pandemic. ¹ Often, discussions of housing in the context of SUD focus on homelessness, particularly the high rates of SUD among people experiencing homelessness and the difficulty in helping them enter and continue SUD treatment. ² Placement in structured residential SUD treatment programs is often seen as a means of housing people with complex substance use and social risk factors. These programs, which often last 30-90 days, are costly and difficult to access. ³ This focus on residential treatment beds can divert attention and resources from outpatient programs, which have lower thresholds for admission and continued engagement than the more intensive residential programs, and from permanent housing solutions. Although the health care sector and policy makers have identified increasing the number of short-term treatment beds as a priority, ⁴ they have devoted limited focus on barriers and facilitators to long-term housing solutions for people with SUD and their households.

People with SUD face several interconnected challenges to finding and maintaining adequate housing. First, compared with the general population, people with SUD have a disproportionately lower income, weaker social networks, and less social capital, which can limit opportunities to connect to supportive services and resources. ⁵ People with SUD may have unstable employment and limited access to friends and family members who are able to provide temporary housing or connections to long-term housing. Second, they face the harmful perception rooted in stigma that people with a history of drug use, even people in long-term recovery, are risky and unreliable tenants. ⁶ This perception can lead private landlords to engage in housing discrimination by denying housing to people whom they perceive to be involved in drug use, even if these people can pay for housing. Third, because selling and possessing many types of drugs is illegal, landlords may be concerned about potential legal problems related to drug-related crime and overdoses on their properties. ⁷

Facing these and other barriers, people with SUD may rely on or require federal housing assistance, which is administered through local public housing authorities (PHAs). Federal programs typically limit household spending on housing costs (eg, rent, utilities) through various mechanisms, including public housing, Housing Choice vouchers, and project-based vouchers. Public housing refers to properties owned and operated by PHAs; public housing was previously the predominant form of housing assistance. ⁸ PHAs also administer Housing Choice vouchers, which enable households to rent homes in the private market and oversee project-based vouchers (or multifamily properties), which have subsidies that are tied to particular units. Across these programs, tenants typically contribute 30% of their household income toward rent and utilities, and the remaining rent and utilities (up to some maximum amount) are covered by the housing subsidy. The voucher-based programs require PHAs to work with landlords and developers; PHAs may also contract with service providers and others to meet their tenants’ needs.

Although these programs offer opportunities to address housing needs for people with SUD, challenges persist. PHAs that administer these programs are agencies that operate within federal guidelines, but they also can have substantial leeway to initiate local programs, albeit dependent on funding availability. PHAs have historically partnered with public health entities on challenges such as tobacco, obesity, and mental health. ⁹

This commentary explores the potential for health care providers to partner with PHAs to support people with SUD, especially amid the opioid crisis. We draw on primary data collected in partnership with the Council of Large Public Housing Authorities (CLPHA), a membership organization that represents PHAs in large US cities and counties. CLPHA members include 68 PHAs that own and manage more than 40% of all public housing and one-quarter of Housing Choice vouchers in the United States. Larger PHAs have outpaced smaller PHAs in forging partnerships with the health care sector. ¹⁰ Thus, the results of these large PHAs may reflect a best-case scenario, recognizing that SUD exacts an enormous toll in more rural areas, where small PHAs are more likely to operate. ¹¹

We administered an online survey from September to November 2019 to all 68 CLPHA members, 43 (63%) of whom responded. The results suggest several opportunities for health care providers and PHAs to work together to remove barriers for long-term housing solutions and forge pathways to treatment for PHA residents with SUD.

Housing Options and Support for People With SUD

PHAs reported various partnerships and approaches designed to house people with SUD. Most PHAs (89.2%; 33 of 37 respondents to the item) reported using project-based vouchers for people with SUD. Nearly two-thirds of respondents also reported having permanent supportive housing models (62.2%; 23 of 37), a broad class of housing programs that provides supplemental on-site assistance to help clients meet their needs. A similar proportion of respondents (67.6%; 25 of 37) reported having Housing First programs, a type of permanent supportive housing in which abstention from drugs and alcohol, or engagement in treatment, is not a prerequisite. Housing First clients may be more likely than clients in other housing programs to stay engaged in medication treatment for SUD. ¹² Compared with participants in programs prioritizing treatment before housing, Housing First participants may be less likely to misuse substances. ¹³ Data also show reductions in use of emergency medical services over time. ¹⁴ Finally, about half of PHAs (52.8%; 19 of 36) reported partnerships with time-limited recovery housing providers (eg, alcohol- and drug-free living that involves peer support). Building on these partnerships is necessary to develop strategies to transition people in these time-limited housing spots to long-term housing supports provided through PHAs.

Despite these programs, respondents indicated that the need for new vouchers (70.6%; 24 of 34 respondents to the question) and for more permanent supportive or sponsor-based housing (88.2%; 30 of 34) is critical to meeting the increased demand for housing people with SUD. Sponsor-based housing can be used to house populations that may face additional challenges obtaining housing through traditional tenant-based vouchers, including as a result of SUD or previous involvement in the criminal justice system. ¹⁵ In this model, residents live in housing that is owned or units that are leased by a partnering agency on behalf of the PHA. Partnering agencies also connect residents to or directly provide on-site supportive services. ¹⁶ However, many PHAs are prohibited from entering into the types of leasing agreements that are necessary for sponsor-based housing. Thus, expanding these programs will not only require additional funding but will also need to address existing statutory barriers.

Beyond the provision of housing through these programs, PHAs reported having various on-site programs and partnerships designed to promote SUD recovery, including counseling and self-help groups. For example, 25.0% of PHAs (9 of 36 respondents to the item) reported the presence of on-site counseling with a credentialed mental health or addiction professional (Figure). In addition, 16.7% of PHAs (6 of 36) indicated on-site self-help groups, such as 12-step programs or Narcotics Anonymous. The overlap between programs designed for people with SUD and people with mental health issues is an area for further research and program development.

Figure.

Percentage of on-site and off-site provisions for recovery support and overdose prevention services among large public housing authorities (N = 43) who responded to an online survey, United States, September–November 2019. Abbreviation: PHA, public housing authority.

Substantial potential also exists for public health agencies to work with PHAs on safety issues related to substance use. One prevention strategy might involve developing a partnership in which the local PHA operates secure receptacles for safe disposal of medications (reported by only 3% of PHAs as an on-site resource). Public health agencies could partner with PHAs to provide sharps (eg, syringe) disposals, a service that benefits people who inject drugs and people who administer medications with syringes (eg, people with diabetes). Only 8% of PHAs that responded offer on-site syringe disposal. Efforts to reduce risk and promote safety may also be explicitly tied to harm reduction strategies. For example, 16.2% (6 of 37 respondents to the item) reported distributing naloxone to staff members and providing training on its use. Naloxone training and distribution programs, which public health agencies or other harm-reduction community-based organizations could facilitate, can improve the recognition of opioid overdose and prompt administration of naloxone, thereby averting opioid overdoses. ^17,18

Criminal History and Look-Back Periods

Having a history of alcohol or drug use or a criminal record may restrict access to housing assistance programs. As part of the “war on drugs,” the aggressive campaign of enforcement activities targeting people involved in the illegal drug trade, including drug consumers, laws were enacted—including the Anti-Drug Abuse Act of 1988, ¹⁹ the Quality Housing and Work Responsibility Act of 1998, ²⁰ the Cranston-Gonzalez National Affordable Housing Act of 1990, ²¹ and the Housing Opportunity Program Extension Act of 1996 ²² —that addressed requirements of public safety, exclusion of applicants, and eviction. In 2015, the US Department of Housing and Urban Development issued guidance indicating that these limitations should focus on convictions rather than arrests. ²³ The intention of this guidance was to offer increased flexibility for PHAs to provide housing for people with a history of drug-related law enforcement encounters. Even so, federal guidance permits PHAs to focus on drug-related convictions that may be minor (eg, misdemeanors for drug possession with no intent to distribute), which could perpetuate discrimination against groups disproportionately affected by the war on drugs, such as African American people. Within existing regulations, PHAs have discretion in setting local standards, often in excess of federal requirements to ban individuals and households for drug-related activities. ²⁴

Our survey results confirm wide variation in look-back periods, during which criminal activity related to substance use would bar applicants from receiving housing assistance. Of 32 respondents to the item, 10 (31.3%) reported look-back periods of <5 years, 13 (40.6%) reported look-back periods of 5 years, and 7 (21.9%) reported look-back periods of >5 years. The median look-back period was 5 years, ranging from 2-10 years in our survey; 2 of 32 (6.3%) PHAs reported considering criminal history regardless of timeframe. Many PHAs also confirmed that applicants for housing assistance are evaluated using a broad framework, with 87.5% of PHAs (21 of 24 respondents to the item) saying that engagement in treatment may be a mitigating factor that could enable applicants to receive housing assistance. Indeed, 70.6% of PHAs (24 of 34 respondents) reported that their agency would be able to approve a public housing applicant despite a previous drug-related conviction for possession and, among PHAs that would be able to approve an applicant, 87.5% (21 of 24 respondents) would consider whether the offender has successfully completed a drug treatment program in their evaluation. Reducing look-back periods could be an important strategy for reducing institutionalized SUD-related stigma.

Seven of 33 PHAs (21.2%) reported that criminal activity related to drug possession is frequently a primary factor in public housing eviction. In addition, 38.2% of PHAs (13 of 34 respondents) indicated that if a resident is at risk for eviction in part due to SUD, the agency has a process for referring residents to recovery services. Connecting residents at risk of eviction to treatment and supportive services may be an important tool in reducing the material harms of SUD.

Discussion

Subsidized housing is a critical resource for people with SUD, yet the public housing sector has not been fully used to help meet their needs. The experience of large PHAs reveals successes and challenges. Most large PHAs maintain relationships with addiction treatment providers, and a few offer onsite counseling, clinical services, or self-help programs. However, levels of engagement in overdose prevention is not high, which is a missed opportunity for communities to reduce the number of fatal overdoses. Given that more overdoses take place in people’s homes than in public places, ²⁵ comprehensive public health strategies should ensure naloxone is readily available in residential settings. Although providing access to naloxone may be difficult to implement in “scattered site” housing, where assisted housing units are widely dispersed in a geographic area, it should be a priority for larger housing communities. We also found that many PHAs are using their flexibility to consider shorter look-back periods for drug-related criminal offenses, which could help lessen the disadvantage of a criminal record.

The findings of our assessment had several limitations. First, survey data were self-reported and may have been prone to recall and social desirability bias. Second, it is uncertain whether responses reflect practices that are widespread in PHAs or initiatives undertaken in a small number of buildings and units. Third, the survey reflects the views of large PHAs; approaches used by small and medium PHAs may differ. Finally, it is unclear whether the service providers that PHAs partner with follow evidence-based practices, such as promoting access to medications for opioid use disorder.

Public Health Implications

Several areas could be targeted to improve the delivery of housing services for people with SUD. First, although most PHAs in our study maintain vouchers for permanent supportive housing and Housing First services, a widely recognized unmet need exists for housing people with SUD who are not yet in recovery but for whom housing could help to facilitate recovery. Study respondents named the expansion of these types of programs as a high priority.

Second, a reliable funding stream is needed to support housing services for people with SUD. One possibility is to provide dedicated vouchers for people in recovery, as was provided in the SUPPORT Act. ²⁶ However, when new vouchers are provided, they should not be provided at the expense of housing slots that could be made available for other clients. Because housing assistance is not an entitlement program, only one-quarter of all eligible households currently receive housing assistance. ²⁷ These vouchers could be funded in several ways. One option is to invest health care resources in social determinants of health; for example, through investments made by health care systems and by enabling health insurers to pay for housing support services, as is increasingly being tested as part of Centers for Medicare & Medicaid Services waivers. ^28,29 At the same time, advocacy to increase the total number of housing vouchers to meet the demand and direct support for people with SUD is critical, especially advocacy that includes both housing and health care advocates.

Third, the affordable housing sector could be brought together more consistently to develop strategies with public health agencies and with other health care partners. For example, many local public health agencies and communities have organized overdose task forces or issued response plans, but PHAs and the broader housing community are not always included in these discussions. Furthermore, the quality of SUD treatment varies; many SUD treatment programs do not provide evidence-based services and may, in fact, offer treatments that are more harmful than helpful. ³⁰ Facilitating connections between housing experts and substance use experts could ensure that the SUD treatment programs with which PHAs form relationships are those that provide evidence-based services. Building these partnerships could facilitate stronger sharing of information, help build alliances across various organizational cultures, and allow for creativity in developing new programs that can conform to the regulations and requirements of federal and state programs. Partnerships with other health care partners can also be used to develop and expand services for people with SUD, identifying gaps in the treatment and services continuum and working to fill those gaps. Identifying funding and resources to develop and sustain these partnerships is crucial.

Fourth, PHAs could share knowledge and best practices with one another. PHAs are able to identify what works in particular contexts, reflect on lessons learned, and spread information to other PHAs that may face similar challenges and opportunities. Knowledge sharing may be particularly beneficial in reorienting housing toward harm reduction housing models, in which housing is provided to people who are not abstinent from drugs or alcohol. Making these changes will require overcoming ingrained resistance and stigma toward people who actively use drugs, a group that is often viewed unfavorably by society. ³¹

Finally, it is critical to remain nimble to evolving challenges. The overdose crisis has changed rapidly in recent years and is likely to continue to transition from one driven mostly by opioid overdoses to one that also involves methamphetamine, cocaine, and new synthetic drugs. ³² This evolution will necessitate various approaches and interventions. Furthermore, COVID-19 is a profound risk to the health and safety of all residents of public housing, but it poses even greater risks among people with serious illnesses, including people with SUD and people with unstable housing. ³³ Careful attention should be paid to the ways that SUD intersects with assisted housing to provide the greatest opportunities to respond to these challenges.

ORCID iD

Craig Evan Pollack, MD, MHS https://orcid.org/0000-0003-2464-6415