Reflections from interviewing overdose survivors who were living on the street

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Since November 2019, ICH has been collaborating with the Boston Public Health Commission, Boston Medical Center, and the BU School of Public Health on the Boston Overdose Linkage to Treatment Study (BOLTS), funded by a grant from RIZE Massachusetts Foundation. BOLTS is a qualitative research study that is examining racial/ethnic inequities in access to treatment for people who recently experienced an opioid overdose in Boston. For the study, we interviewed 59 Boston residents who had recently experienced an opioid overdose. Most of our recruitment was done in the Mass. and Cass area of Boston, and the majority of the people we talked with were experiencing homelessness at the time of their interview, with 29 living on the street. 

In October 2021, the City of Boston declared addiction and homelessness to be a public health crisis, and began efforts to clear tent encampments from the Mass. and Cass area. Because of this, our team conducted an expedited sub-analysis to elevate the perspectives of people who were living on the street in the Mass. and Cass area when they were interviewed for BOLTS. Our report is available here, and we are sharing it widely to ensure that policymakers, program leaders, and other decision-makers can learn directly from the insights and perspectives of people who are living with substance use disorders and homelessness.  

Hearing participants’ stories was deeply moving and powerful for our team, and we recently reflected on this work and what we learned from participants. You can read perspectives from some of our study team members here, centered around a common theme of how social determinants of health and substance use disorders are deeply intertwined. 

One of the ideas that came up in many of the interviews I did was that having your basic needs met is very much connected to accessing treatment or changing one’s drug use. These basic needs include housing, health care, being treated with respect, food, sanitation, a good-paying job, and a place to be safe – among others. While there are a lot of improvements that can be made to address the treatment system, we can’t do that in a vacuum. Another thing I heard is that for some people treatment isn’t always their #1 goal, or even their #3 or #5 goal that they want to work on. For some, treatment is a stepping stone for something else they hope to achieve. – Jeff Desmarais, Institute for Community Health 

One major finding that I want people to take away from this work is that many people are using drugs as a way to cope with trauma, mental health issues that are not being properly treated, and the trauma of housing insecurity. – Shannon O’Malley, Boston Public Health Commission 

One takeaway from this work that really resonated with me is that person’s substance use disorder is only one part of their overall life – when we think about how to support people on a path to recovery, we need to think about more than just getting someone into a treatment program. We need to understand the circumstances that affect quality-of-life, and provide services and supports that address social and medical needs going beyond substance use disorder treatment. For example, if a person is homeless and is struggling to find a job due to having a history of justice system involvement, going to a treatment program isn’t going to solve those problems. Without support around housing and employment, the person’s overall life circumstances are unlikely to get better – in fact, they may even feel worse because of the removal of drug use as a coping mechanism. – Ranjani Paradise, Institute for Community Health 

In this BOLT Study sub-analysis, several participants spoke about the difficulty of finding and maintaining access to treatment while unhoused, explaining that the often chaotic nature of homelessness precludes them from considering personal needs beyond immediate survival and safety at any given time. One participant stated “the most important thing to recovery is knowing you have a safe place to go every night.” The current housing options are insufficient: gaps in the residential treatment continuum of care, negative experiences at local shelters, and long wait times for housing contribute to participants’ inability to find long-term housing and their mental exhaustion when attempting to do so. Our findings have thus made even clearer that a successful treatment system necessitates a departure from the idea of social determinants of health as distinct, rather than overlapping. In addition to housing and treatment, access to economic stability, education, comprehensive healthcare, environmental stability, and community support is most effective when considered together. – Al Nurani, Boston Medical Center 

In my perspective, these points from the report are most important to elevate: Many participants identified homelessness as a major impediment to achieving and maintaining SUD recovery. In the words of one participant, “the most important thing to recovery is knowing you have a safe place to go every night.” In addition, for many, the current shelter system is not perceived as a viable alternative to living on the streets, due to shelter conditions, lack of sense of safety, and/or poor treatment by staff. – Dan Dooley, Boston Public Health Commission