Experiencing homelessness as a risk factor for negative treatment outcomes among individuals receiving outpatient treatment for opioid use disorder in the United States

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Erik Friesen
Samantha Young



Introduction People experiencing homelessness (PEH) have disproportionately high rates of opioid use disorder (OUD) and are at high risk of opioid-related morbidity and mortality. The purpose of this study was to evaluate the impact of homelessness on treatment-related outcomes among individuals receiving outpatient treatment for OUD.


Methods The data for this study came for the Treatment Episodes Dataset - Discharges (TEDS-D), a large, nationally representative discharge database for addiction treatment facilities in the United States (US). The cohort was restricted to individuals receiving treatment for OUD. Four treatment-related outcomes were explored: the use of opioid agonist therapy (OAT), treatment retention, treatment discontinuation, and treatment completion. The associations between homelessness and these four outcomes were analyzed using multivariable logistic regression models adjusted for clinically relevant covariates (age, sex, prior addiction treatment, primary OUD type, psychiatric comorbidity, and polysubstance use). State-level differences in the association between homelessness and treatment outcomes were assessed and mapped.


Results Experiencing homelessness was associated with a lower odds of receiving OAT (adjusted odds ratio (aOR): 0.69, 95% confidence interval (CI): 0.67 - 0.72) and treatment retention (aOR: 0.66, 95% CI: 0.64 - 0.68). Homelessness had a smaller but statistically significant effect on treatment discontinuation and completion, where it increased the odds of client dropout (aOR: 1.09, 95% CI: 1.06 - 1.14) and decreased the odds of completion (aOR: 0.91, 95% CI: 0.87 - 0.95). The associations between homelessness and OAT use and homelessness and retention varied substantially between states.


Conclusion In this large, US cohort of individuals receiving outpatient treatment for OUD, experiencing homelessness was associated with worse treatment outcomes than clients who were stably housed. The reduced odds of receiving OAT among PEH is particularly concerning given the other forms of structural marginalization this population faces that are associated with higher risk of poor health outcomes.