Abstract
Objective:
We sought to identify the sociodemographic and clinical characteristics associated with homelessnesss, and explore the relationship between homelessnesss and treatment outcomes among Black individuals.
Methods:
This is a secondary analysis of the subgroup of Black participants (n=73) enrolled in “X:BOT,” a 24-week multisite randomized clinical trial comparing the effectiveness of extended-release naltrexone vs. sublingual buprenorphine-naloxone (n=570). Outcomes included: medication initiation, return to extra-medical use of opioids assessed by both self-report and urine toxicology, and engagement in medications for opioid use disorder (MOUD) treatment at 28 weeks post-randomization. Descriptive statistics were performed.
Results:
Black participants were mostly unmarried and male, and about a third were age 21-30. Among people experiencing homelessnesss, more were uninsured (45.5% [10/22] vs. 19.6% [10/51]), unemployed (77.3% [17/22] vs. 64.7% [33/51]), and reported alcohol (40.9% [9/22] vs. 23.5% [12/51]) and sedative use (54.5% [12/22] vs. 17.6% [9/51]) within the previous 30 days. Compared to housed Black individuals, a slightly higher proportion of Black individuals experiencing homelessnesss successfully initiated study medication (81.1% [18/22] vs. 72.6% [37/51]); similar proportions returned to opioid use during the trial (68.2% [15/22] vs. 68.6% [35/51]) and were engaged in MOUD at 28 weeks after trial entry (72.2% [13/18] vs. 69.7% [23/33]) among participants located for follow-up.
Conclusions:
These descriptive results among Black patients participating in a trial of MOUD suggest efficacious MOUD is possible despite homelessnesss with additional clinical supports such as those provided by a clinical trial.
Keywords: Black/African American, homeless persons, Opioid use disorder
INTRODUCTION
Although less often discussed, the Black community has been highly impacted by the opioid epidemic. Medications for opioid use disorder (MOUD), including extended release naltrexone and sublingual buprenorphine-naloxone, are Food and Drug Administration-approved medications for OUD, yet have consistently been shown to be disproportionately underutilized by Black Americans, largely due to inequitable access.1 Additionally, in 2020, Black individuals experienced the largest increase in overdose mortality when compared to White individuals.2
There are an estimated 2.5 to 3.5 million Americans experiencing homelessness.3 People experiencing homelessnesss (PEH) are disproportionately impacted by the opioid epidemic, with PEH experiencing more fatal and non-fatal overdose than housed people,4 and drug-related overdose representing the leading cause of death among PEH.5
Black individuals are considerably overrepresented within the homeless population in the United States, composing 39 percent of all PEH, but only 12 percent of the total US population.6 Our objective was to explore differences in treatment outcomes by housing status within a sample of Black participants enrolled in a randomized controlled trial that compared the effectiveness of extended release naltrexone and sublingual buprenorphine-naloxone.
METHODS
Participants
We conducted a secondary analysis of X:BOT, a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) funded 24-week, randomized clinical trial comparing the effectiveness of extended-release naltrexone versus sublingual buprenorphine-naloxone.7 Enrolled participants (N=570): 1) were treatment seeking adults over the age of 18, 2) had a diagnosis of OUD (based on the Diagnostic and Statistical Manual of Mental Disorders-5 criteria), 3) used non-prescribed opioids in the 30 days prior to recruitment, 4) spoke English, and 5) had no other serious medical disorders. We recruited participants from eight geographically disparate, community-based, inpatient, detoxification centers and randomly assigned them to receive either extended release naltrexone or sublingual buprenorphine-naloxone.
We conducted a secondary exploratory analysis among the subset of participants who self-reported as Black (n=73), comparing those who were homeless to those who were housed. We opted not to use race-based comparisons in this study based on previous work that has shown that such comparisons may fail to recognize structural and cultural factors that may influence treatment effects.8
Measures
We administered a demographic assessment at study screening that collected information about patient gender, age, ethnicity, race, education, employment status and marital status. Attitudes and expectations regarding study medications, as well as previous treatment attempts were collected once at screening. Participants were considered houseless if at baseline they answered “yes” to the question “are you currently homeless or living in a shelter?” as a part of a quality of life survey. Outcomes of interest included: 1) successful medication initiation, 2) return to extra-medical opioid use (relapse to use of opioids in a way other than prescribed), and 3) engagement with MOUD at 28 weeks.
Analysis
We conducted descriptive analyses of the sociodemographic characteristics, clinical characteristics, and outcomes of interest among the intention-to-treat sample of Black participants, stratified by homelessness. Prior to computing descriptive statistics, we examined all variables for distribution and outliers. We used frequencies and proportions to describe binary and categorical variables, and used medians and interquartile ranges to avoid bias by small sample size or by skewness of the distribution within continuous variables.
RESULTS
Sample Demographics
Characteristics of the sample are reported in Table 1.
Table 1:
Sociodemographic, clinical, and substance use demographics stratified by housing status.
| Total (n=73) |
Homeless (n=22) |
Housed (n=51) |
||||
|---|---|---|---|---|---|---|
| Variables | n | % | n | % | n | % |
| Treatment Arm | ||||||
| Buprenorphine | 36 | 49.3% | 11 | 50.0% | 25 | 49.0% |
| Naltrexone | 37 | 50.7% | 11 | 50.0% | 26 | 51.0% |
| Gender | ||||||
| Male | 59 | 80.8% | 19 | 86.4% | 40 | 78.4% |
| Female | 14 | 19.2% | 3 | 13.6% | 11 | 21.6% |
| Age | ||||||
| <=20 | 2 | 2.7% | 2 | 9.1% | 0 | 0.0% |
| 21-30 | 21 | 28.8% | 3 | 13.6% | 18 | 35.3% |
| 31-40 | 15 | 20.5% | 2 | 9.1% | 13 | 25.5% |
| 41-50 | 20 | 27.4% | 11 | 50.0% | 9 | 17.6% |
| >50 | 15 | 20.5% | 4 | 18.2% | 11 | 21.6% |
| Marital Status | ||||||
| Married/Remarried/Living Together | 12 | 16.4% | 4 | 18.2% | 8 | 15.7% |
| Widowed/Separated/Divorced | 9 | 12.3% | 1 | 4.5% | 8 | 15.7% |
| Never Married | 51 | 69.9% | 17 | 77.3% | 34 | 66.7% |
| Unknown | 1 | 1.4% | 0 | 0.0% | 1 | 2.0% |
| Insurance | ||||||
| Uninsured | 20 | 27.4% | 10 | 45.5% | 10 | 19.6% |
| Medicare/Medicaid | 49 | 67.1% | 10 | 45.5% | 39 | 76.5% |
| Private | 4 | 5.5% | 2 | 9.1% | 2 | 3.9% |
| Parole/Probation | ||||||
| No | 59 | 80.8% | 19 | 86.4% | 40 | 78.4% |
| Yes | 14 | 19.2% | 3 | 13.6% | 11 | 21.6% |
| Education | ||||||
| <High School | 21 | 28.8% | 7 | 31.8% | 14 | 27.5% |
| High School/General Educational Development |
22 | 30.1% | 6 | 27.3% | 16 | 31.4% |
| >High School | 30 | 41.1% | 9 | 40.9% | 21 | 41.2% |
| Employment | ||||||
| No | 50 | 68.5% | 17 | 77.3% | 33 | 64.7% |
| Yes | 23 | 31.5% | 5 | 22.7% | 18 | 35.3% |
| History of Psychiatric Disorder | ||||||
| No | 41 | 56.2% | 11 | 50.0% | 30 | 58.8% |
| Yes | 32 | 43.8% | 11 | 50.0% | 21 | 41.2% |
| Primary Drug | ||||||
| Opioid Analgesics | 7 | 9.7% | 0 | 0.0% | 7 | 14.0% |
| Heroin | 65 | 90.3% | 22 | 100.0% | 43 | 86.0% |
| Cost of Primary Drug [Median (IQR)] | 73 | 60.0 (40.0-100.0) | 22 | 50.0 (40.0-80.0) | 51 | 60.0 (40.0-120.0) |
| Duration of Use [Median (IQR)] | 73 | 10.0 (5.0-23.0) | 22 | 20.5 (9.0-29.0) | 51 | 8.0 (5.0-20.0) |
| Use in past 30 days: | ||||||
| Smoking | ||||||
| No | 10 | 13.7% | 3 | 13.6% | 7 | 13.7% |
| Yes | 63 | 86.3% | 19 | 86.4% | 44 | 86.3% |
| Alcohol to Intoxication | ||||||
| No | 52 | 71.2% | 13 | 59.1% | 39 | 76.5% |
| Yes | 21 | 28.8% | 9 | 40.9% | 12 | 23.5% |
| Amphetamines | ||||||
| No | 67 | 91.8% | 20 | 90.9% | 47 | 92.2% |
| Yes | 6 | 8.2% | 2 | 9.1% | 4 | 7.8% |
| Sedatives | ||||||
| No | 52 | 71.2% | 10 | 45.5% | 42 | 82.4% |
| Yes | 21 | 28.8% | 12 | 54.5% | 9 | 17.6% |
| Cannabis | ||||||
| No | 38 | 52.1% | 13 | 59.1% | 25 | 49.0% |
| Yes | 35 | 47.9% | 9 | 40.9% | 26 | 51.0% |
| Cocaine | ||||||
| No | 33 | 45.2% | 10 | 45.5% | 23 | 45.1% |
| Yes | 40 | 54.8% | 12 | 54.5% | 28 | 54.9% |
| Treatment Variables: | ||||||
| No strong medication preference | ||||||
| Disagree | 24 | 32.9% | 5 | 22.7% | 19 | 37.3% |
| Neutral | 25 | 34.2% | 8 | 36.4% | 17 | 33.3% |
| Agree | 24 | 32.9% | 9 | 40.9% | 15 | 29.4% |
| Prefer Buprenorphine | ||||||
| Disagree | 16 | 21.9% | 5 | 22.7% | 11 | 21.6% |
| Neutral | 33 | 45.2% | 11 | 50.0% | 22 | 43.1% |
| Agree | 24 | 32.9% | 6 | 27.3% | 18 | 35.3% |
| Prefer Naltrexone | ||||||
| Disagree | 13 | 17.8% | 4 | 18.2% | 9 | 17.6% |
| Neutral | 38 | 52.1% | 11 | 50.0% | 27 | 52.9% |
| Agree | 22 | 30.1% | 7 | 31.8% | 15 | 29.4% |
| First Treatment | ||||||
| No | 40 | 54.8% | 14 | 63.6% | 26 | 51.0% |
| Yes | 33 | 45.2% | 8 | 36.4% | 25 | 49.0% |
| Past Successful Treatment | ||||||
| No | 44 | 60.3% | 12 | 54.5% | 32 | 62.7% |
| Yes | 29 | 39.7% | 10 | 45.5% | 19 | 37.3% |
| Past Successful Treatment (Buprenorphine or Methadone) | ||||||
| No | 49 | 67.1% | 15 | 68.2% | 34 | 66.7% |
| Yes | 24 | 32.9% | 7 | 31.8% | 17 | 33.3% |
| Past Successful Treatment (Naltrexone) | ||||||
| No | 69 | 94.5% | 20 | 90.9% | 49 | 96.1% |
| Yes | 4 | 5.5% | 2 | 9.1% | 2 | 3.9% |
Clinical Characteristics and Substance Use History:
The majority of Black participants reported heroin as their primary opioid used (90.3% [65/73]). Black participants reported spending an average of $60 (IQR=$40-100) per day on opioids and had a median duration of use of 10 years (IQR=5-23).
More Black PEH had a history of psychiatric disorders compared to housed individuals (50.0% [11/22] vs. 41.2% [21/51]). A larger percent of Black PEH were likely to endorse heroin as their primary opioid of use (100% [22/22] vs. 86% [43/51]), and spent less on opioids daily ($50; IQR=$40-80 vs $60; IQR=$40-120), but report a longer duration of use (20.5 years; IQR=9.0-29.0 vs 8.0; IQR=5.0-20).
Recent alcohol (40.9% [9/22] vs. 23.5% [12/51]) and sedative (54.5% [12/22] vs. 17.5% [9/51]) use was more common among PEH. PEH did not endorse a strong treatment preference for either extended release naltrexone or sublingual buprenorphine-naloxone (40.9% [9/22] vs. 29.4% [15/51]), and reported greater prior treatment success (45.5% [10/22] vs. 37.3% [19/51]) when compared to housed participants.
Treatment Outcomes:
A majority of Black participants successfully initiated study medication, experienced return to extra-medical opioid use, and were engaged in MOUD treatment at 4 weeks following study termination (Table 2). Compared to housed individuals, a slightly higher proportion of PEH had successful initiation to study medication (81.1% [18/22] vs 72.6% [37/51]), but similar proportions of return to extra-medical opioid use (68.2% [15/22] vs. 68.6% [35/51]) and engagement with MOUD at 4 weeks following study termination (72.2% [13/18] vs. 69.7% [23/33]).
Table 2:
Study outcomes based on housing status.
| Overall Sample % (n) |
Homeless % (n) |
Housed % (n) |
|
|---|---|---|---|
| Induction status | |||
| No | 24.7 (18) | 18.2 (4) | 27.5 (14) |
| Yes | 75.3 (55) | 81.8 (18) | 72.5 (37) |
| Return to extra-medical opioid use | |||
| No | 31.5 (23) | 31.8 (7) | 31.4 (16) |
| Yes | 68.5 (50) | 68.2 (15) | 68.6 (35) |
| MOUD engagement at 28 weeks | |||
| No | 29.4 (15) | 27.8 (5) | 30.3 (10) |
| Yes | 70.6 (36) | 72.2 (13) | 69.7 (23) |
DISCUSSION
To our knowledge, very few studies have examined the impact of homelessnesss on MOUD treatment outcomes within Black individuals.9 Compared to Black housed participants, a greater proportion of Black PEH in our study were uninsured and unemployed. These findings underscore the importance of insurance expansion within Black PEH with OUD, as it is established that insurance status is correlated with receipt of MOUD, and that lack of insurance can serve as a hurdle to treatment engagement within this population.10 This could be accomplished through policy change such as Medicaid expansion, which has been shown to increase access to MOUD within Black patient populations.11
It is well established that PEH experience psychiatric illness at higher rates than housed individuals, and this was supported by findings in our study.12 Within our study, we found that more Black PEH reported polysubstance use with alcohol and sedatives. Because both psychiatric diagnoses and polysubstance use are risk factors for poor treatment outcomes, linking mental health care and alcohol and sedative treatment to MOUD treatment could serve as a useful intervention strategy among Black PEH.10
Our study found that Black PEH had a slightly greater proportion of successful treatment initiation when compared to Black housed individuals. Previous literature for this outcome has mixed results. Studies exemplifying lower rates of MOUD initiation within PEH primarily took place in outpatient settings, while higher rates of medication initiation were seen in inpatient settings and detoxification centers.13,14
We found similar proportions of return to extra-medical opioid use and engagement with MOUD at 28 weeks between Black PEH and housed participants. Previous studies have similarly demonstrated no difference in retention with the implementation of added supports such as care coordinators, psychoeducational groups, individual counseling, and most importantly, the provision of housing.15
This study has several limitations. First, the sample size of Black participants was small, preventing us from performing statistical comparison and limiting study power. Confidence limits on differences observed were wide, making it uncertain how meaningful differences may be. Because the sample included patients admitted to an inpatient unit, results may not be generalizable to the majority of people with OUD, who primarily seek outpatient treatment.
Our findings suggest that successful treatment of OUD in PEH is possible with additional support provided by a clinical trial. While the exact methods of improving treatment access and retention among Black PEH remain to be understood, our findings suggest that low barrier MOUD access within this population may be improved through expansion of employment and insurance resources, concomitant substance use treatment, and mental health treatment.
Funding:
Primary study funded by National Institute on Drug Abuse: UG1 DA013035 and T32 DA007294
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