摘要：Objectives. We examined whether cocaine-dependent homeless persons had stable housing and were employed 6, 12, and 18 months after they entered a randomized controlled trial comparing 2 treatments. Methods . One group (n = 103) received abstinence-contingent housing, vocational training, and work; another group (n = 103) received the same intervention plus cognitive behavioral day treatment. We examined baseline and early treatment variables for association with long-term housing and employment. Results . Although the enhanced-treatment group achieved better abstinence rates, the groups did not differ in long-term housing and employment stability. However, consecutive weeks of abstinence during treatment (and to a lesser extent, older age and male gender) predicted long-term housing and employment stability after adjustment for baseline differences in employment, housing, and treatment. Conclusions . Our data showed a relationship of abstinence with housing stability. Contrasting these results with the increasingly popular Housing First interventions reveals important gaps in our knowledge to be addressed in future research. Homelessness remains a major problem despite considerable public awareness and publicly funded interventions. 1 – 3 Prevalence of US homelessness per day in 2007 was estimated to be 671 788. 4 Although the estimated prevalence of alcohol and substance use disorders among homeless persons varies depending on where and how data are collected, national cross-sectional surveys suggest that 38% have past-year alcohol problems and 46% have past-year drug problems, and both co-occur with mental illness. 5 The health, mortality, and criminal justice implications of homelessness have been well-studied and reflect increased societal costs when homelessness and its correlates are poorly addressed. 6 – 8 We developed and evaluated an effective intervention for homeless cocaine-dependent persons in several randomized controlled trials conducted in Birmingham, Alabama. 9 – 11 The most recent trial, Homeless 4, 12 treated 2 groups with abstinence-contingent housing and work therapy (for 6 months), which had been found in earlier trials to be more effective than either not providing housing or providing housing without an abstinence contingency. One Homeless 4 group (treatment) received 6 months of abstinence-contingent housing and work training alone; the other group (enhanced treatment) received the same contingency management plus daily cognitive behavioral day treatment. We used rigorous methods to diagnose mental illness and measure abstinence (defined as zero use of alcohol and common illicit drugs), housing, and employment stability throughout treatment and in follow-ups at 6, 12, and 18 months. We examined whether superior long-term housing and employment stability were related to the superiority in long-term abstinence achieved by the enhanced-treatment group. We addressed 3 research questions: (1) What is the effect of treatment group on housing and employment stability over time? (2) Does sustained abstinence achieved during treatment and aftercare contribute to long-term housing and employment stability? (3) What other factors predict housing and employment outcomes? Investigating housing and employment outcomes in this context is relevant to the literature on Housing First, 13 which places no preconditions on the receipt of housing, and more traditional treatment-oriented, linear approaches to housing, which connect it to treatment. Many communities rely on addiction treatment as a point of entry to treatment for a major subset of the homeless population, it is therefore important to determine whether long-term housing and employment are achieved by persons who pursue effective addiction treatments.
