Background: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.
DoranKM, RahaiN, McCormackRPSubstance use and homelessness among emergency department patients. Drug Alcohol Depend. 2018;188:328–333.
2.
McCormackRP, HoffmanLF, NormanM, GoldfrankLR, NormanEM.Voices of homeless alcoholics who frequent Bellevue Hospital: a qualitative study. Ann Emerg Med. 2015;65(2):178–186.e6.
3.
MabhalaMA, YohannesA, GriffithM.Social conditions of becoming homelessness: qualitative analysis of life stories of homeless peoples. Int J Equity Health. 2017;16(1):150.
4.
HamiltonAB, PozaI, WashingtonDL. Homelessness and trauma go hand-in-hand: pathways to homelessness among women veterans. Womens Health Issues. 2011;21(4 Suppl):S203–S209.
5.
Ross-HouleK, VenturasC, BradburyA, PorcellatoL.An exploration of the role of alcohol in relation to living situation and significant life events for the homeless population in Merseyside, UK. Alcohol Research UK. 2017.
6.
FazelS, KhoslaV, DollH, GeddesJ.The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.
7.
Center for Behavioral Health Statistics and Quality. Results from the 2019 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020. https://www.samhsa.gov/data/. Published August 2020. Accessed February 6, 2021.
8.
HenwoodBF, PadgettDK, SmithBT, TideringtonE.Substance abuse recovery after experiencing homelessness and mental illness: case studies of change over time. J Dual Diagn. 2012;8(3):238–246.
9.
PadgettDK, HenwoodB, AbramsC, DrakeRE.Social relationships among persons who have experienced serious mental illness, substance abuse, and homelessness: implications for recovery. Am J Orthopsychiatry. 2008;78(3):333–339.
10.
PahwaR, SmithME, YuanY, PadgettD.The ties that bind and unbound ties: experiences of formerly homeless individuals in recovery from serious mental illness and substance use. Qual Health Res. 2019;29(9):1313–1323.
11.
ShinnM, KnickmanJR, WeitzmanBC.Social relationships and vulnerability to becoming homeless among poor families. American Psychol. 1991;46(11):1180–1187.
12.
PadgettDK, SmithBT, Choy-BrownM, TideringtonE, MercadoM.Trajectories of recovery among formerly homeless adults with serious mental illness. Psychiatr Serv. 2016;67(6):610–614.
13.
HopperK, JostJ, HayT, WelberS, HauglandG.Homelessness, severe mental illness, and the institutional circuit. Psychiatr Serv. 1997;48(5):659–665.
14.
JohnsonTP, FendrichM.Homelessness and drug use: evidence from a community sample. Am J Prev Med. 2007;32(6 Suppl):S211–S218.
15.
MetrauxS, CusackM, ByrneTH, Hunt-JohnsonN, TrueG.Pathways into homelessness among post-9/11-era veterans. Psychol Serv. 2017;14(2):229–237.
16.
VandykAD, HarrisonMB, VanDenKerkhofEG, GrahamID, Ross-WhiteA.Frequent emergency department use by individuals seeking mental healthcare: a systematic search and review. Arch Psychiatr Nurs. 2013;27(4):171–178.
17.
DoranKM, RavenMC, RosenheckRA.What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013;62(2):151–159.
18.
DoranKM, KunzlerNM, MijanovichTHomelessness and other social determinants of health among emergency department patients. J Soc Distress Homeless. 2016;25(2):71–77.
19.
MalechaPW, WilliamsJH, KunzlerNM, GoldfrankLR, AlterHJ, DoranKM.Material needs of emergency department patients: a systematic review. Acad Emerg Med. 2018;25(3):330–359.
20.
BisgaierJ, RhodesKV.Cumulative adverse financial circumstances: associations with patient health status and behaviors. Health Soc Work. 2011;36(2):129–137.
21.
SalhiBA, WhiteMH, PittsSR, WrightDW.Homelessness and emergency medicine: a review of the literature. Acad Emerg Med. 2018;25(5):577–593.
22.
AndersonES, HsiehD, AlterHJ.Social emergency medicine: embracing the dual role of the emergency department in acute care and population health. Ann Emerg Med. 2016;68(1):21–25.
23.
AndersonES, LippertS, NewberryJ, BernsteinE, AlterHJ, WangNE.Addressing social determinants of health from the emergency department through social emergency medicine. West J Emerg Med. 2016;17(4):487–489.
24.
DoranKM, RanZ, CastelblancoD, ShelleyD, PadgettDK. It wasn't just one thing: a qualitative study of newly homeless emergency department patients. Acad Emerg Med. 2019;26(9):982–993.
25.
PadgettD.Qualitative Methods in Social Work Research. 3rd ed. Los Angeles, CA: Sage Publications; 2017.
26.
SmithPC, SchmidtSM, Allensworth-DaviesD, SaitzR.A single-question screening test for drug use in primary care. Arch Gen Intern Med. 2010;170:1155–1160.
27.
SmithPC, SchmidtSM, Allensworth-DaviesD, SaitzR.Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24(7):783–788.
28.
PattonM.Qualitative Research and Evaluation Methods. 3rd ed. Thousand Oaks, CA: Sage Publications; 2002.
29.
Dedoose Version 8.0.42 Web Application for Managing, Analyzing, and Presenting Qualitative and Mixed Method Research Data. Los Angeles, CA: SocioCultural Research Consultants, LLC; 2018.
30.
Eyrich-GargKM, CacciolaJS, CariseD, LynchKG, McLellanAT.Individual characteristics of the literally homeless, marginally housed, and impoverished in a US substance abuse treatment-seeking sample. Soc Psychiatry Psychiatr Epidemiol. 2008;43(10):831–842.
31.
HawkinsRL, AbramsC.Disappearing acts: the social networks of formerly homeless individuals with co-occurring disorders. Soc Sci Med. 2007;65(10):2031–2042.
32.
BoothBM, SullivanG, KoegelP, BurnamA.Vulnerability factors for homelessness associated with substance dependence in a community sample of homeless adults. Am J Drug Alcohol Abuse. 2002;28(3):429–452.
33.
DoranKM, RavenMC.Homelessness and emergency medicine: where do we go from here?Acad Emerg Med. 2018;25(5):598–600.
34.
Rojas SmithL, HaberS, Armstrong BrownJAccountable Health Communities (AHC) Model Evaluation First Evaluation Report. Baltimore: Center for Medicare & Medicaid Innovation; 2020.
35.
YoungMM, StevensA, GalipeauJEffectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review. Syst Rev. 2014;3:50.
36.
BarataIA, ShandroJR, MontgomeryMEffectiveness of SBIRT for alcohol use disorders in the emergency department: a systematic review. West J Emerg Med. 2017;18(6):1143–1152.
37.
MoeJ, KirklandSW, RaweEEffectiveness of interventions to decrease emergency department visits by adult frequent users: a systematic review. Acad Emerg Med. 2017;24(1):40–52.
38.
FormosaEA, KishimotoV, Orchanian-CheffA, HaymanK.Emergency department interventions for homelessness: a systematic review. CJEM. 2021;23(1):111–122.
39.
WalterLA, SchoenfeldEM, SmithCH,et al. Emergency department-based interventions affecting social determinants of health in the United States: a scoping review. Acad Emerg Med. 2021;28(6):666–669.
WelchAE, JeffersA, AllenB, PaoneD, KuninsHV. Relay: a peer-delivered emergency department-based response to nonfatal opioid overdose. Am J Public Health. 2019;109(10):1392–1395.
42.
GoedelWC, MarshallBDL, SamuelsEARandomised clinical trial of an emergency department-based peer recovery support intervention to increase treatment uptake and reduce recurrent overdose among individuals at high risk for opioid overdose: study protocol for the navigator trial. BMJ Open. 2019;9(11):e032052.
43.
SalhiBA.Who are Clive's friends? Latent sociality in the emergency department. Soc Sci Med. 2020;245:112668.
44.
RedelmeierDA, MolinJP, TibshiraniRJ.A randomised trial of compassionate care for the homeless in an emergency department. Lancet. 1995;345(8958):1131–1134.
45.
ClarkHW, PowerAK.Women, co-occurring disorders, and violence study: a case for trauma-informed care. J Subst Abuse Treat. 2005;28(2):145–146.
46.
DoranKM, JohnsE, SchretzmanMHomeless shelter entry in the year after an emergency department visit: results from a linked data analysis. Ann Emerg Med. 2020;76(4):462–467.
47.
LinkBG, PhelanJC.Conceptualizing Stigma. Annu Rev Sociol. 2001;27(1):363–385.
48.
PhelanJC, LinkBG, TehranifarP.Social conditions as fundamental causes of health inequalities: theory, evidence, and policy implications. J Health Soc Behav. 2010;51(Suppl):S28–S40.
49.
LinkBG, PhelanJ.Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94.
50.
AhernJ, StuberJ, GaleaS.Stigma, discrimination and the health of illicit drug users. Drug Alcohol Depend. 2007;88(2–3):188–196.
