Faculty Bibliography

INTRODUCTION/BACKGROUND:The overdose crisis in the U.S. disproportionately impacts people experiencing homelessness. Permanent supportive housing (PSH) - permanent, affordable housing with voluntary support services - is an effective, evidence-based intervention to address homelessness. However, overdose risk remains high even after entering PSH for individual and structural reasons. In this study, we aimed to refine a set of evidence-based overdose prevention practices (EBPs) and an associated implementation support package for PSH settings using focus groups with PSH tenants, frontline staff, and leaders. METHODS:Our community-academic team identified an initial set of overdose EBPs applicable for PSH through research, public health guidance, and a needs assessment. We adapted these practices based on feedback from focus groups with PSH leaders, staff, and tenants. Focus groups followed semi-structured interview guides developed using the EPIS (Exploration, Preparation, Implementation, Sustainment) framework constructs of inner context, outer context, and bridging factors related to overdose prevention and response. RESULTS:We conducted 16 focus groups with 40 unique participants (14 PSH tenants, 15 PSH staff, 11 PSH leaders); focus groups were held in two iterative rounds and individuals could participate in one or both rounds. Participants were diverse in gender, race, and ethnicity. Focus group participants were enthusiastic about the proposed EBPs and implementation strategies, while contributing unique insights and concrete suggestions to improve upon them. The implementation support package contains an iteratively refined PSH Overdose Prevention (POP) Toolkit with 20 EBPs surrounding overdose prevention and response, harm reduction, and support for substance use treatment and additional core implementation strategies including practice facilitation, tenant-staff champion teams, and learning collaboratives. CONCLUSIONS:This manuscript describes how robust community-academic partnerships and input from people with lived experience as tenants and staff in PSH informed adaptation of evidence-based overdose prevention approaches and implementation strategies to improve their fit for PSH settings. This effort can inform similar efforts nationally in other settings serving highly marginalized populations. We are currently conducting a randomized trial of the refined overdose prevention implementation support package in PSH.

On a single night in 2023, more than 653,000 people experienced homelessness in the United States. In this overview, we highlight structural and individual risk factors that can lead to homelessness, explore evidence on the relationship between homelessness and health, discuss programmatic and policy innovations, and provide policy recommendations. Health system efforts to address homelessness and improve the health of homeless populations have included interventions such as screening for social needs and medical respite programs. Initiatives using the Housing First approach to permanent supportive housing have a strong track record of success. Health care financing innovations using Medicaid Section 1115 waivers offer promising new approaches to improving health and housing for people experiencing homelessness. To substantially reduce homelessness and its many adverse health impacts, changes are needed to increase the supply of affordable housing for households with very low incomes. Health care providers and systems should leverage their political power to advocate for policies that scale durable, evidence-based solutions to reduce homelessness, including increased funding to expand housing choice vouchers and greater investment in the creation and preservation of affordable housing.

IMPORTANCE/UNASSIGNED:Emergency departments (EDs) serve patients at high risk for overdose. There is increasing interest in peer-delivered ED interventions for substance use but little rigorous research on their effectiveness. OBJECTIVE/UNASSIGNED:To examine the effectiveness of an initiative (Relay) operated by the New York City Health Department that dispatches trained peer wellness advocates (WAs) to support ED patients after a nonfatal opioid overdose. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This randomized clinical trial compared Relay and site-directed care (SDC) at 4 EDs in New York, New York. Adult patients presenting after opioid-involved overdose were enrolled from October 6, 2020, to June 30, 2022, with 12 months of outcome follow-up. Statistical analysis was performed from November 4, 2024, to May 6, 2025. INTERVENTION/UNASSIGNED:ED workers (generally physicians) called the Relay hotline for patients presenting after a suspected opioid-involved overdose. WAs met patients in the ED to provide peer support and brief overdose risk reduction education. WAs attempted to contact patients for 90 days to provide ongoing support, education, and referrals using a harm reduction framework. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Opioid-related adverse events (any opioid-involved overdose [fatal or nonfatal] or any other substance use-related ED visit) in the 12 months after enrollment were identified using health care administrative data plus self-report. RESULTS/UNASSIGNED:Among a total of 253 participants randomized, 127 were randomized to the Relay arm and 126 to the SDC arm. A total of 247 participants, 125 in the Relay arm and 122 in the SDC arm (190 [76.9%] men; 80 [32.4%] Black, 126 [51.0%] Hispanic or Latinx, 76 [30.8%] White, and 91 other race [36.8%]), were included in the intention-to-treat analyses. No statistically significant differences between arms were observed for the primary outcome (mean [SD] opioid-related adverse events, 3.29 [4.52] in the Relay arm and 4.10 [9.36] in the SDC arm; rate ratio, 1.02; 95% CI, 0.72-1.45; P = .90). By 12 months after enrollment, 24 participants (9.7%) had died (17 [70.8%] due to overdose). Relay participants reported high satisfaction with the ED intervention. CONCLUSIONS AND RELEVANCE/UNASSIGNED:This randomized clinical trial examining the impact of an ED peer navigator intervention on subsequent opioid-related adverse events did not find significant outcome differences for Relay vs SDC participants. These findings highlight the importance of intervening to save lives in this high-risk population and suggest potential refinements to future ED peer intervention research. TRIAL REGISTRATION/UNASSIGNED:ClinicalTrials.gov Identifier: NCT04317053.

BACKGROUND:The COVID-19 pandemic presented significant new needs and challenges for people experiencing homelessness (PEH) and people with substance use disorders (SUDs). In response, program leaders modified existing programs and developed new ones to meet these needs during a unique policy and public health environment. This study aimed to examine how these innovations unfolded and what lessons can be learned from their implementation. METHODS:We performed in-depth, semi-structured qualitative interviews with key informants (n = 37 informants) from programs serving PEH and addressing substance use created or adapted during the COVID-19 pandemic in the United States (U.S.) and Canada. Informants spanned a wide range of backgrounds, program types, and geographic locations. We completed rapid sequence qualitative analysis using templated summaries for each interview, which we compiled into a summary matrix. We reviewed the summary matrix to identify key topics and develop a code list that was applied to transcripts using line-by-line coding. Results from rapid analysis and line-by-line coding were discussed iteratively to develop and refine key themes. RESULTS:Key informants described innovations including SUD treatment and harm reduction interventions via telemedicine, hotel shelters, and street outreach. Interviews revealed four overarching themes related to innovation implementation: (1) Removal of usual bureaucratic barriers and easing of regulations facilitated action, (2) Individuals stepped up and said, "We're gonna do it," (3) Stigma and mixed attitudes about harm reduction impacted the implementation of pandemic innovations, and (4) Innovations in shelter and SUD care delivery for PEH during the COVID-19 pandemic resulted in durable lessons and new program models. CONCLUSIONS:A combination of individual action and systemic changes produced new innovations to address the intersecting issues of homelessness and substance use during the COVID-19 pandemic. Lessons from these innovations can inform sustained improvements in SUD care for PEH.

OBJECTIVES/OBJECTIVE:Fentanyl test strips (FTS) have the potential to moderate drug use behavior amidst an unregulated drug supply, yet are underutilized in medical settings. We aimed to describe emergency department (ED) FTS distribution across a large NYC health system and examine characteristics associated with clinicians' ordering FTS compared with the current standard-of-care, take-home naloxone (THN), to identify opportunities to optimize FTS distribution. METHODS:We conducted a retrospective review of THN and FTS provision across a large urban health system in its first year of FTS distribution. We evaluated the demographic and clinical characteristics of visits in which clinicians ordered FTS, compared with THN only. RESULTS:From July 20, 2022 to July 20, 2023, 237 (of 423) clinicians ordered THN for 1279 unique individuals in 1376 eligible visits (436 with FTS, 940 without). In pairwise analysis, FTS receipt was associated with being male, younger, non-White, lacking commercial insurance; substance-related or overdose-related visit chief complaint or diagnosis, attending physician, and patient-directed discharge ( P <0.05 for each). In multivariable regression, higher odds of FTS receipt were associated with male gender (OR=2.4; 95% CI=1.8-3.5), a substance-related chief complaint (OR=2.0; 95% CI=1.2-3.2) or visit diagnosis (OR=5.5; 95% CI=3.8-8.0), and overdose visit diagnosis (OR=1.7; 95% CI=1.1-2.8). Lower odds of FTS receipt were associated with older age (OR=0.98; 95% CI=0.97-0.99), noncommunity hospital sites (OR=0.71; 95% CI=0.60-0.83), and non-attending clinicians (OR=0.83; 95% CI=0.69-0.98). CONCLUSIONS:Integrating FTS into an existing ED THN program was feasible without disrupting clinical workflow. ED encounters where FTS were dispensed differed significantly from THN-only, revealing opportunities to optimize FTS ordering.

BACKGROUND:Permanent supportive housing (PSH) is an evidence-based intervention for people experiencing homelessness which integrates permanent housing with voluntary support services. PSH tenants are at high risk for overdose death, yet little research to date has examined overdose in PSH. We sought to examine overdose risk and existing responses in PSH, which can shed light on opportunities for future overdose prevention efforts. METHODS:We conducted focus groups with PSH tenants, staff, and leaders in New York City and New York's Capital Region. Focus groups were recorded and professionally transcribed. Two investigators independently completed rapid turnaround qualitative analysis, completing templated summaries of each focus group and compiling key content in an analysis matrix, which a third investigator reviewed; discrepancies were resolved by consensus. RESULTS:From October to December 2022, we held 8 focus group sessions with PSH tenants (3 focus groups, n = 10 total participants), staff (3 focus groups, n = 13), and leaders (2 focus groups, n = 11) grouped by role and region. Participants were diverse in age (26-67 years), gender (18 women, 16 men), race (3 Asian, 12 Black, 11 White, 5 multiracial, 3 other), and ethnicity (5 Latinx, 29 not Latinx). Analysis revealed four main themes: (1) Overdose was a large concern in PSH and created significant trauma for tenants and staff; (2) Environmental factors in PSH contributed to overdose risk; (3) There was heterogeneity in PSH buildings' current overdose prevention efforts and adoption of harm reduction principles; and (4) Multifactorial barriers resulted in limited tenant use of opioid agonist treatment. CONCLUSIONS:Overdose is a major concern for PSH tenants, staff, and leaders. Our findings shed new light on overdose in PSH settings, providing insight into risk factors, existing responses, and barriers and facilitators to future overdose prevention efforts. These findings can inform future overdose prevention interventions within PSH. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov, NCT05786222, registered 27 March 2023.

BACKGROUND:The COVID-19 pandemic led to disruptions in substance use and harm reduction services for people experiencing homelessness (PEH) as well as opportunities to innovate. Pandemic-era innovations may offer insights on more effective approaches to the intertwined issues of homelessness and substance use beyond the pandemic. We present findings from a scoping literature review of articles describing interventions related to substance use and homelessness that emerged during the pandemic. METHODS:We conducted a scoping literature review to identify articles on pandemic-era innovations related to substance use and homelessness. We completed a comprehensive search for articles in nine academic and grey literature databases in November 2022, and a second database search in September 2023. We screened titles, abstracts, and full text using predefined inclusion and exclusion criteria. We extracted data on study design, location, participants, and outcomes. RESULTS:Database searches yielded 812 unique articles; 68 met inclusion criteria. Most articles discussed interventions addressing opioid use (n = 60). Commonly described interventions included telemedicine-based prescribing of medications for opioid use disorder (MOUD), homeless services site-based MOUD provision, managed alcohol programs, supervised consumption services, and safer supply prescribing. Articles reported few intervention-related adverse effects, though study designs (e.g., non-experimental, observational studies lacking comparison groups) presented limitations to effectiveness outcome assessment. Surmountable challenges associated with interventions included inequitable access to technology for PEH. CONCLUSIONS:Innovations in programs that provide substance use treatment and harm reduction services to PEH were observed during the COVID-19 pandemic. Further evidence is needed to determine which COVID-19 pandemic-related innovations were most impactful and how they should be prioritized and continued post-pandemic.