Kevin Scott was in his early teens when he began using drugs and alcohol. Since that time, he's experienced homelessness and has struggled with chronic pain from back, neck and head injuries.
Now 48, Scott has secured a stable footing in life, in part because he now has a home. He won't lose his apartment in Seattle's Plymouth Housing program if he does drugs; in fact, Scott is not entirely substance-free. But now that he is free from the stress and uncertainty of the streets, Scott has been able to reduce his use dramatically, participating in a combined behavioral and pharmacotherapy program through the Harm Reduction Research and Treatment (HaRRT) Center and Harborview Medical Center. The program has helped him switch from hard drugs like heroin and methamphetamines to cannabis, and limit his alcohol use. He participates in vocational rehabilitation, has an emotional support dog and volunteers to cook community meals for others in his housing complex. "It's been my anchor," Scott says.
His case is just one example of how psychosocial supports can change lives. Opioid addiction is unique in that there are very effective medications that block opioid receptors to reduce cravings and even save lives in the event of overdose. But some people are reluctant to use medications or are unable to stick to a medication plan because of instability in their lives. Others want to taper off medications over time or need to relearn how to be in the world without substances, says Katie Witkiewitz, PhD, a professor of psychology at the University of New Mexico Center on Alcoholism, Substance Abuse and Addictions. Psychosocial support programs focused on getting substance users into stable housing, bringing together their family members and loved ones, addressing their employment problems and dealing with legal problems stemming from their drug use can make sticking with a broader treatment plan possible.
"A lot of the work focuses on the underlying issues that brought people to addiction in the first place," says Witkiewitz.
For someone struggling with an opioid use disorder, these supports can make all the difference.
A safe harbor
Traditionally, housing programs have asked people with substance use disorders to "prove" themselves before receiving housing, says clinical psychologist Susan Collins, PhD, the co-director of the HaRRT Center at the University of Washington School of Medicine in Seattle. They might have had to commit to substance use treatment programs or provide negative drug tests before they were considered "housing-ready."
But that philosophy is amiss, Collins says. "What agencies were finding was that the most stable parts of the homeless community were getting housing. But the folks who were struggling the most—and were the most marginalized—were not," she says.
Will Williams, a member of the community advisory board for the HaRRT Center, was once reluctant even to try to get permanent housing because he knew he would "screw it up" if he had to abide by rules like not smoking cigarettes or marijuana.
"You might be surprised how harmful being told that you can't do something is to a person who already feels they've been pushed around, pushed around, pushed around," Williams says.
In response, the philosophy of "housing first" was born. Housing First programs, the first of which was established in 1988, aim to get homeless people, whether they use substances or not, into housing with few strings attached.
"We know that housing forms the basic platform that folks need in order to even begin to think about how to heal," says Karen DuBois-Walton, PhD, a clinical psychologist and president of the Elm City Communities/Housing Authority of New Haven, Connecticut.
Many cities across the United States now have Housing First programs, funded through a variety of federal subsidies, resident rent payments, grants and donations. The funding perpetually lags behind the need, DuBois-Walton says, especially because home prices and rents have risen faster than income over the past several decades, putting affordable housing in increasingly short supply.
For those who do gain a spot in them, Housing First communities provide an entryway into treatment, with services ranging from on-site case management to behavioral health treatments. Being late on the rent won't trigger eviction proceedings. Rather, DuBois-Walton says, late rent is seen as a first sign that someone might be relapsing or otherwise in need of help. Many of these supportive housing communities that serve people with opioid use histories distribute naloxone (also known as Narcan) to residents and staff and hold trainings on how to use the kits in case a resident overdoses.
Research on using the Housing First approach with opioid users is relatively sparse compared with research on its use with alcohol or polysubstance users. However, polysubstance use is the norm for people with opioid use disorder, Collins says, and the available evidence suggests the intervention works similarly across substance use disorders: People don't miraculously become abstinent as a result of getting housing, but they don't start using more, as some critics have worried. Overall, they appear to experience fewer negative health outcomes and have a better chance of getting treatment.
One study led by Philip Appel of the New York State Office of Alcoholism and Substance Abuse Services examined a Housing First program in New York and found that about half of homeless, mentally ill methadone patients who secured housing were adhering to their methadone treatment three years later, compared with just 20 percent of the same population who did not receive housing (Journal of Addictive Diseases, Vol. 31, No. 3, 2012).opens in new window
Another study led by Sara Miller-Archie of the New York City Department of Health and Mental Hygiene found that among polysubstance users in the city, those placed in supportive housing were hospitalized less, used emergency departments less, and were more likely to initiate substance use treatment than those not given such housing (Annals of Epidemiology, in pressopens in new window).
However, a study of homeless adults receiving methadone maintenance treatment in Vancouver, Canada, by Simon Fraser University clinical psychologist Julian Somers, PhD, and colleagues found that Housing First programs didn't increase methadone treatment adherence any more than treatment as usual, leading the authors to conclude that housing supports were not in themselves sufficient to improve treatment adherence (International Journal of Drug Policy, Vol. 56, 2018opens in new window). That study did not examine other outcomes like hospitalizations.
Help at work
For many people who use opioids, struggles with stable work go hand-in-hand with housing struggles. But there are few direct workplace supports for people who use opioids, says Kenneth Silverman, PhD, a professor of psychiatry and behavioral services at The Johns Hopkins University School of Medicine. Silverman and his colleagues run a work program for people with substance use disorders who are chronically unemployed. The program takes a contingency-management approach: Participants are paid to do data entry, and to earn maximum pay, they must also submit substance-free urine samples regularly. The key for achieving abstinence seems to be a combination of workplace incentives and medication treatment, the team has found, an example of social support and medical treatment working in tandem (Drug and Alcohol Dependence, Vol. 197, 2019opens in new window). Employees aren't fired for relapsing, as they might be in a typical workplace.
"Our people need more than a second chance," Silverman says.
Silverman says his program, which is funded by federal grants, would be hard to reproduce in most employment settings. At most companies, employees with substance use problems who aren't simply fired are likely to get treated through employee assistance programs, which are often limited to short-term counseling and referrals.
But some employers are getting interested in providing more support and second chances. Belden, a computer and telecommunications hardware company, has a "Pathways to Employment" programopens in new window that lets job applicants who are rejected because of a failed drug screening participate in rehabilitation and try again. Contractors such as American Substance Abuse Professionals Inc.opens in new window work with employers to develop treatments for employees who have failed drug screenings, particularly in jobs with high safety standards, such as transportation and nuclear energy.
Silverman and his team are in the midst of a study that recruits participants to work in their data-entry business for 90 days and then engage with an employment specialist for a year to find paid work outside the study. As long as they remain abstinent during this time, they receive a stipend.
"You need high-magnitude incentives, and you need to maintain those for long periods of time," Silverman says. "That's one of the motivations for using employment because employment can involve high-magnitude incentives, long-term."
Family therapy
Loved ones can also be a potent force in supporting the recovery of people with opioid use disorder. Family therapy can help families create a healthy environment around a member who is using drugs, help repair relationships fractured by drug use and help families support their loved one's recovery.
"Whether you're a teenager or a young adult or you're 40 years old, you have family, and the family can support recovery or they can undermine it," says Gayle Dakof, PhD, a clinical psychologist and professor of public health at the University of Miami and director of MDFT International.
Often, patients come to treatment still enmeshed in relationships with other substance users, says Hortensia Amaro, PhD, a psychologist at Florida International University who founded a long-standing residential substance use treatment program for Latina mothers, called Entre Familia, in Boston. Those patients have to reconstruct their social circles and find ways to navigate or disengage from toxic relationships, Amaro says.
Family involvement is especially important for adolescents who use substances, says Kimberly Kirby, PhD, a professor of psychology at Rowan University in New Jersey, and programs have been developed to help even when a loved one is resistant to treatment. Community Reinforcement and Family Training (CRAFT) is a program that teaches families to interact with a substance-using member by using positive reinforcement and improving communication and other relationship skills. This approach has been shown for decades to move more people with substance use problems into treatment than other family support options like Al-Anon and Nar-Anon or traditional interventions, according to research by Hendrick G. Roozen, PhD, of Erasmus University Medical Centre in Rotterdam (Addiction, Vol. 105, No. 10, 2010opens in new window).
Kirby and her team have found that one particular aspect of CRAFT—treatment entry training, or training families to look for the fleeting moments when loved ones may be open to treatment and teaching them how to phrase their requests to get help—can be effective on its own in increasing treatment entry rates (Psychology of Addictive Behaviors, Vol. 31, No. 7, 2017opens in new window).
Other effective family-oriented approaches include multisystemic therapy (MST) and multidimensional family therapy (MDFT). Both programs differ from CRAFT in that they focus on directly treating substance use as well as building family relationships. There are differences between the programs. MST, for example, focuses on treating adolescents in their homes, schools and neighborhoods, and always includes parents in counseling sessions with youth. MDFT is implemented in community settings as well as inpatient facilities and prescribes solo counseling with youth as well as joint sessions with parents. But both ultimately focus on healing the family and enhancing positive social supports. MST has been shown to be one of the most effective interventions for teenagers who use substances and have conduct problems (Substance Abuse: Research and Treatment, Vol. 6, 2012opens in new window). MDFT, which is Dakof's treatment focus, is also highly rated for efficacy, as shown in a meta-analysis by Thimo van der Pol of Leiden University and colleagues (Journal of Child Psychology and Psychiatry, Vol. 53, No. 5, 2017opens in new window). One particularly meaningful aspect of MDFT for opioid-using teens is the sessions in which they and their families meet to discuss an overdose prevention and safety plan.
"The idea is to stimulate an emotional conversation about drugs and about overdose and about death and life, and so on, to get people motivated to help each other," Dakof says.
These programs have high success rates, but a persistent problem is that they're not available everywhere and that families don't know about them, Kirby says. Access to these family-focused therapies for substance use is "really not great," she says.
Support, not punishment
Instead of accessing effective treatments, people who use drugs often land in the criminal justice system. With the deepening of the opioid crisis, police, district attorneys and the courts are increasingly playing the role of lifeline rather than disciplinarian.
The problem is serious. Some 58 percent of state prisoners and 63 percent of sentenced jail inmates met the criteria for drug use or dependence, as of 2009 (Bureau of Justice Statistics, 2017opens in new window). Jails and prisons aren't drug-free zones; a few years ago, Seattle's Scott says, he was jailed. He came out hooked on methamphetamines.
"Jail isn't a good place for addicts," he says.
For people with opioid use disorder in particular, imprisonment and its aftermath can be life-threatening. One meta-analysis found that among this population, overdose deaths increase three- to eightfold within the first four weeks of release from prison, because if they aren't using regularly while incarcerated, people with opioid use disorder lose their tolerance to heroin and other opioids (Merrall, E., et al., Addiction, Vol. 105, No. 9, 2010opens in new window).
Another meta-analysis found that offering medications for addiction treatment may help—methadone, buprenorphine or naltrexone treatment during incarceration increase substance use treatment entry, and methadone also reduces opioid use after release (Moore, K.E., et al., Journal of Substance Abuse Treatment, Vol. 99, 2019).
States are slowly taking notice: Rhode Island started screening every inmate for opioid use disorder and offering counseling and medication in 2016. California's Department of Health Care Services is funding the expansion of medication treatment for opioid addiction in the corrections system in 22 counties. The federal prison system is gradually coming around, too. In December, President Donald Trump signed the First Step Act, a criminal justice reform bill, into law. The law includes a mandate that the federal prison system expand evidence-based treatment for opioid dependence, including both medication and what the law calls "holistic" approaches.
A more well-established route is to usher people with substance use disorder out of the regular court system and into drug courts, where a judge supervises every aspect of treatment and recovery. These courts are popular because they reduce recidivism and cost less than the standard court-and-corrections process, Dakof says. The first drug court was established in Miami in 1989, and there are now more than 3,000 nationwide.
But drug courts don't always implement the best evidence-based treatments, Dakof says. Very few, for example, implement MDFT or MST for juveniles, even though those approaches have some of the best evidence for the longest-lasting effects.
Because high-quality service is key to a successful drug court, psychologists can play important roles in them, and not just in treatment, says Richard Wiener, PhD, a professor of psychology at the University of Nebraska–Lincoln.
"It's getting to the point now where people are thinking about accountability issues and professionalization in drug courts. There is a major role for psychologists, and in fact, the organizational and research role may be the most prominent," Wiener says.
Wiener is now involved in drafting standards for Nebraska's mental health courts, an expansion of the drug-court model. Besides writing standards, he says, psychologists can help teach lawyers, who are trained to defend their clients, to instead think about the best way to get them treatment and services.
"There is an effort to look at things like education, housing, employment, social support, social security and insurance," Wiener says. "It's not just the substance use problem and mental health problems. It's a social service agenda of things people need in order to be successful."
