1 Sydney Russell

Final Recommendation

A Recommendation for the Homelessness and Opioid Crisis

I. Section 1

A. Introduction

Does homelessness cause mental illness, or does mental illness cause homelessness? Both

functioning as major public health problems, the two exacerbate each other. There are temporary

fixes to treating the mentally ill homeless population in various cities across the nation, but few

studies have yet to propose an intervention which addresses the underlying causes and prevents

future cases of mentally ill unhoused individuals. This report focuses on explaining the complex

relationship between mental illness, homelessness, and opioid use, identifying the severity and

impact of the current homeless population, and recommending what America must do to prevent

it from worsening.

Mental illness and drug abuse, particularly of opioids, are very prominent issues in the

American homeless population. Regarding mental illness alone, the U.S. Conference of Mayor’s

Report on Hunger and Homelessness found 58% of homeless were mentally ill in 20161. Through

multiple reports each year in various cities, the findings stay consistent: homeless individuals have

a higher incidence of mental illness than the general population 2. Mental illnesses disrupt an

individual’s ability to perform daily activities that otherwise would be achievable, such as self-

care and household management. Additionally, mental illnesses, “prevent people from forming

and maintaining stable relationships or cause people to misinterpret others’ guidance and react

irrationally” 3. This can easily cause poor relationships among one’s workplace, family members,

or friends, resulting in a higher chance of losing the resources necessary to keep living in a home.
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The existing data on the topic illustrates how current interventions are failing to properly address

solutions to mental illness among the homeless.

In many situations, mental illness goes hand in hand with drug addiction, especially if the

individual does not have basic necessities such as a home. The National Institute on Drug Abuse

found that, “data from a large nationally representative sample suggested that people with mental,

personality, and substance use disorders were at increased risk for nonmedical use of prescription

opioids”4. Additionally, 43 percent of people receiving treatment for substance abuse disorder for

nonmedical use of prescription painkillers have a diagnosis or symptoms of mental health

disorders, particularly depression and anxiety4. Although both pressing issues affect the same

population, it is difficult to establish causality between drug addiction and mental illness. Many

studies fail to accurately identify when drug use or addiction started, especially because data

collection relies heavily on personal recollection, resulting in recall bias 5. Plus, behavioral and

emotional problems may never be correctly diagnosed due to limited access to healthcare or the

severity of the problem may not be enough for an official diagnosis5. These factors make it

difficult to understand which health problem came first.

B. Population

Homelessness is a crisis that has existed for centuries and is still very prominent in King

County and across America. For example, King County relies on volunteers to physically count

the number of homeless individuals living in shelters or on the streets one night each year, in the

annual One Night Count. In January 2017, 11,643 individuals were found living in homeless

conditions after the One Night Count6. Afterwards, a survey was administered to a randomized

sample of individuals experiencing homelessness to identify certain demographic characteristics

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about the King County homeless population. Of the survey respondents, 45% admitted to suffering

from a psychiatric or emotional condition, 34% admitted to suffering from post - traumatic stress

disorder, and 36% reported drug or alcohol abuse6. From the most recent data collected, mental

illness and drug abuse are pressing issues in Seattle’s homeless community.

C. Impacts

Economic & Financial Impacts

The cost of healthcare has been a major issue for Americans to afford compared to people

living in other countries. Especially for low income and homeless families, it is difficult to afford

health insurance and quality treatment for illnesses. Although the government has attempted to

supplement suffering individuals through food stamps, Social Security Disability Insurance

(SSDI) and Supplemental Security Income (SSI) cash assistance, and public housing financed by

federal and state revenues, this is seen as a temporary fix. Not only is homelessness expensive for

the public as a whole, but homelessness combined with mental illness and addiction causes intense

financial burdens on the affected population as well.

Any type of medical care costs money, especially if it requires transportation to a hospital

in an ambulance, receiving IV fluids, or being prescribed a medication. The Substance Abuse and

Mental Health Services Administration in their 2011 National Survey on Drug Use and Health

found that 50.1% of the 4.9 million adults surveyed reported they did not receive proper mental

and behavioral health care because of their inability to afford care, and 16.2% did not receive

treatment because they did not know where to go for care 7. This survey did not include homeless

individuals, whom are more likely to not afford treatment or know where to access treatment for

substance abuse disorders or mental illnesses. If this is already an issue in the general population,
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Final Recommendation

the homeless population is at a greater disadvantage for affording and finding care because their

priority is finding a place to live and basic survival needs.

D. Stakeholder Interviews

To investigate the problem from the perspective of someone directly working with this

population, my peers and I interviewed a primary stakeholder on February 4th, 2018. This fifteen-

minute phone interview was held with Shilo Jam who works as the Executive Director of the

People’s Harm Reduction Alliance (PHRA) in Seattle, Washington. His role as the executive

director allows him to travel to different Downtown Emergency Service Center (DESC) sites and

distribute materials such as clean pipes and needles and educate the drug - using population on

how to use properly to reduce subsequent health problems from occurring, such as abbesses and

Hepatitis C. Mr. Jam further explained how homelessness is an ever - expanding problem, and it

will continue to be because of the high cost of living and the housing prices in Seattle. He expressed

his support for treatment on demand (especially Naloxone), the importance of public transportation

and making treatment easily accessible to users. He finished the conversation by stating, “the vast

majority of these people have survived really intense trauma, so the number one thing that needs

change is strong mental health services before anything”. This statement exemplifies the

importance of upstream changes surrounding mental illness treatment, opioid prescriptions, and

affordable housing.

E. What’s Currently Being Done

Many organizations around the country have developed successful techniques to house the

homeless population. One example is the Housing First Model, used at DESC, which prioritizes
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Final Recommendation

fixing homelessness before any other behavioral problems. The logic behind this model surrounds

the idea that if an individual has a stable home and place to reside, the burdens of being homeless

will decrease, and there will be more time and energy to focus on improving other areas of life

such as mental health and addiction. Other cities have established city - sanctioned encampments,

focusing on providing connections to permanent housing, or “tent cities”, which are locations

where homeless individuals are able to reside in tents and require residents to participate in serving

the camp and decision making, providing a sense of ownership and responsibility 8. Programs such

as homeless shelters like DESC and encampments are created to provide stable housing for

homeless individuals, but more action is needed to address behavioral problems within this

population.

Besides local programs such as those previously mentioned, the local, state, and federal

governments have implemented policies that directly impact homelessness, mental illness, and

opioid abuse. For example, Governor Inslee wrote Executive Order 16-09 requesting strategies to

reduce the supply of illegal opioids in Washington State9. This addresses the reality of the opioid

crisis in Washington by setting three goals: (1) prevent inappropriate opioid prescribing and reduce

opioid misuse and abuse, (2) treat individuals with opioid use disorder and link them to support

services, including housing, and (3) intervene in opioid overdoses to prevent death9. On a federal

level, the FY 2017 spending bill (Consolidated Appropriations Act of 2017) provided $2.383

billion for the U.S. Department of Housing and Urban Development's (HUD) McKinney-Vento

Homeless Assistance Grants program, dramatically increasing funding for homeless youth

demonstration projects and homelessness data analysis10. Overall, there are many existing policies

that address homelessness and related problems, but there is still much research needed to end this

epidemic and prevent further development of the problem.

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Final Recommendation

II. Section 2: Recommendation

A. Introduction

After researching the opioid and homeless crisis in Seattle, I realize a key barrier to solving

these complex issues is access to treatment. Most of the past research, initiatives, campaigns, and

policies have focused on addressing homelessness first. I agree this is a necessary step, especially

considering the thought process behind the Housing First Principle previously mentioned.

However, even if policies and programs help organize homeless individuals into shelters, there

must be case managers available to help access proper treatment for any existing mental illnesses

or substance abuse disorders among the sheltered population. For tangible, long term change, this

problem can be fixed by the creation and proper managing of permanent shelters abiding by the

Housing First Model, adequate numbers of staff members and case managers, and reliable

transportation for the shelter residents to attend scheduled mental illness and drug addiction

treatment programs.

Although there are many areas that need addressing, I will focus on increasing access to

treatment from shelters through the format of an advocacy campaign using a digital presentation,

with the intent to increase awareness of this need to King County City Council and the general

public. The presentation will outline the severity of the problem and explain how there are

available shelter and treatment options, but not a feasible connection between them. The goal of

the presentation is to influence policy makers to make this a priority and explain how this problem

could be addressed by presenting possible interventions. I chose to begin implementation in King

County since most of my previous research is centered around the King County homeless

population.
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Final Recommendation

B. Necessary Steps

For successful implementation of this presentation, I must prepare a digital presentation on

PowerPoint and schedule a meeting with King County City Council to deliver the presentation

over the summer of 2018. I will identify as a University of Washington School of Public Health

student and public health advocate, hoping to spare a half an hour of the City Council’s time to

propose possible interventions regarding one of the most prominent public health issues in Seattle.

Within the presentation, I will emphasize how there must be collaboration between many different

organizations and stakeholders who work in some capacity with the homeless population in order

to find an affordable way to transport individuals to treatment. I will explain the state of the

problem, present research that supports my argument, suggest two possible interventions, and end

with thanking the City Council for their previous efforts to combat homelessness in King County.

C. Justification

One possible intervention I will suggest is an increase in funding to existing homeless

shelters around King County. This funding will specifically be used to hire additional employees

with the role to schedule and manage treatment plans with residents needing mental illness or

addiction treatment. With the properly trained staff to organize transportation to treatment

facilities and health centers, this will remove the need for homeless individuals to stress about

finding money and transportation to their appointments. Previous studies found that a very

common problem within shelters is the scheduling of clinic appointments at the same time as the

only offered daytime meals and is a major reason why individuals are not going to treatment 11.

This causes a dilemma the residents must face: food or treatment. It is unfeasible to expect a

homeless individual suffering from mental disorders or substance abuse to manage complicated
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Final Recommendation

schedules and transportation routes to treatment. Yet, with strategic planning of schedules, the

residents will have the ability to eat the offered meals while receiving treatment at other times. As

Shilo Jam mentioned in the stakeholder interview, creating and expanding shelters is not enough.

There must be additional resources within the shelters that increase access to receiving proper

diagnoses and treatment. Since this intervention relies strictly on funding for new staff members,

I will propose another intervention for City Council to consider.

My second intervention will be a partnership between existing homeless shelters (such as

DESC) and a local transportation service, such as Uber, Lyft, or other independently-owned

companies. A study based in Toronto, Canada entitled, “Access to Primary Health Care Among

Homeless Adults in Toronto, Canada: Results from the Street Health Survey”, researched the

barriers the Toronto homeless population faced when accessing health care. The most striking

finding showed that most homeless individuals relied on walk-in clinics and emergency

departments for health care, which is a very expensive avenue to receive basic health needs12. The

greatest disparity faced by this population was access to transportation to health services. By

partnering with local, independent drivers, the homeless shelters can develop a collaboration to

transport residents to appointments, clinics, health centers, and treatment. The transportation

service could offer discount codes or even free rides in return for sponsorship or high ratings. In

2015, a similar intervention was carried out for homeless veterans living in Virginia, in which

Uber and Lyft provided free rides for homeless veterans on Veteran’s Day 13. This intervention

was a part of the Joining Forces Campaign launched by Michelle Obama. The general public

donated money to the cause through the Uber and Lyft phone applications, which was shown to

be incredibly successful. However, this campaign was only used for veterans, and did not apply

to other homeless individuals who did not identify as a veteran. Considering how successful this
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Final Recommendation

program was, I believe a similar intervention targeting homeless opioid users and mentally ill

individuals would dramatically increase their access to treatment.

Overall, my goal with giving this presentation to City Council is to initiate an action-

oriented approach to improving access for vulnerable homeless populations through readily

available transportation. The success of my presentation relies on effectively articulating the

problem and proposed solutions, as well as the sustainability and feasibility of the interventions.

Mental illness, homelessness, and drug abuse are very complex issues without a simple solution.

Yet, spreading awareness and advocating for change is a step in the right direction.

1
Any Mental Illness (AMI) Among U.S. Adults. (2015). Retrieved November 30, 2017, from
https://www.nimh.nih.gov/health/statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml
2
The prevalence of serious mental illness in Washington State: Chapter 7, Laws of 2001, E2, section 204(5)(c)
Chapter 25, Laws of 2003, E1, section 204(5)(b). Dept. of Social & Health Services, Health and Rehabilitation
Service Administration, Mental Health Division, 2003.
3
Mental Illness and Homelessness. (2012, February 21). Retrieved December 01, 2017, from
http://www.nationalhomeless.org/factsheets/Mental_Illness.html
4
Katz C, El-Gabalawy R, Keyes KM, Martins SS, Sareen J. Risk factors for incident nonmedical prescription opioid
use and abuse and dependence: results from a longitudinal nationally representative sample. Drug Alcohol Depend.
2013;132(1-2):107-113. doi:10.1016/j.drugalcdep.2013.01.010.
5
Abuse, N. I. (2018, February). Part 1: The Connection Between Substance Use Disorders and Mental Illness.
Retrieved March 06, 2018, from https://www.drugabuse.gov/publications/research-reports/common-physical-
mental-health-comorbidities-substance-use-disorders/part-1-connection-between-substance-use-disorders-mental-
illness
6
Seattle/King County Point-In-Time County of Persons Experiencing Homelessness. ASR, 2017, Seattle/King
County Point-In-Time Count, allhomekc.org/wpcontent/uploads/2016/11/2017-Count-Us-In-PIT-Comprehensive-
Report.pdf
7
Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use
and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. Rockville,
MD: Substance Abuse and Mental Health Services Administration, 2012.
8
Encampments. (2015). Retrieved March 06, 2018, from http://greaterseattlecares.org/encampments/
9
Exec. Order No. 16-09, 3 C.F.R. 4 (2016). http://www.governor.wa.gov/sites/default/files/exe_order/eo_16-09.pdf
10
Funding For Homelessness Programs. (n.d.). Retrieved March 07, 2018, from
http://cqrcengage.com/naeh/homelessness_programs?0
11
Institute of Medicine . Committee on Health Care for Homeless People. (1988). Homelessness, health, and human
needs. Washington, D.C.: National Academy Press.
12
Khandor, Mason, Chambers, Rossiter, Cowan, & Hwang. (2011). Access to primary health care among homeless
adults in Toronto, Canada: Results from the Street Health survey. Open Medicine : A Peer-reviewed, Independent,
Open-access Journal, 5(2), E94-e103.
13
Malachowski, N. (2015, November 10). Joining Forces to Help Veterans Transition. Retrieved March 07, 2018,
from https://obamawhitehouse.archives.gov/blog/2015/11/10/joining-forces-help-veterans-transition