摘要：Objectives . Housing typically is not provided to homeless persons during drug abuse treatment. We examined how treatment outcomes were affected under 3 different housing provision conditions. Methods . We studied 196 cocaine-dependent participants who received day treatment and no housing (NH), housing contingent on drug abstinence (ACH), or housing not contingent on abstinence (NACH). Drug use was monitored with urine testing. Results . The ACH group had a higher prevalence of drug abstinence than the NACH group (after control for treatment attendance), which in turn had a higher prevalence than the NH group. All 3 groups showed significant improvement in maintaining employment and housing. Conclusions . The results of this and previous trials indicate that providing abstinence-contingent housing to homeless substance abusers in treatment is an efficacious, effective, and practical intervention. Programs to provide such housing should be considered in policy initiatives. Homelessness affects 3.5% to 6.0% of Americans at some point in their lives, and as many as 11.4% of urban women of childbearing age are homeless. 1 – 4 The point prevalence of homelessness has been estimated at 1% of the general US population and 6.3% of people in poverty. 5 , 6 Lack of child care and a history of physical and/or sexual abuse greatly increase risk for homelessness. 7 Homelessness, in turn, increases risk for diseases including HIV, other sexually transmitted diseases, tuberculosis, asthma, and bronchitis. 8 These diseases contribute to morbidity and premature death. 9 – 11 Providing effective drug abuse intervention for homeless substance abusers is a daunting challenge because of this population’s high morbidity, poverty, and social instability. 12 – 19 In particular, homelessness necessitates a continuous search for food and shelter, which seriously interferes with treatment participation. For example, O’Brien et al. 20 found that day treatment reduced drug abuse among non-homeless participants but that no homeless participants were retained in treatment. Previous trials have shown that provision of housing for homeless substance abusers while they are undergoing behavioral day treatment improved addiction outcomes and resulted in less homelessness. 21 , 22 In those studies, housing was available only when participants were drug-free; that is, housing was “abstinence-contingent.” Such a contingency differs greatly from the typical “housing first” approach to fighting homelessness, in which housing is provided with no abstinence requirements, on the premise that housing provision alone will lead to improvement. In theory, non–abstinence-contingent housing for homeless substance abusers in treatment could be less expensive and logistically simpler, because treatment staff would not be required to monitor drug use and implement ejection from housing because of a failed urine test. Some authorities in the field believe non–abstinence-contingent housing to be an easier, cheaper, and more effective way to provide treatment for homeless drug abusers, but until now no studies have examined whether this approach is effective and cost-efficient. In the trial, we examined how providing housing with and without an abstinence contingency affected drug use, homelessness, and employment among cocaine-dependent homeless persons. We considered 2 hypotheses: (1) that the housed groups would have better treatment retention and outcomes than those without housing, and (2) that those who received housing contingent on abstinence would have better outcomes than those who receive housing not contingent on abstinence.
