Full length articleHealth, perceived quality of life and health services use among homeless illicit drug users
Introduction
Homelessness is a significant and growing problem in many developed countries (Edgar et al., 2003). The true extent of the problem is unclear as no universal consensus has been reached on the definition of homelessness (Amore et al., 2011). The European Union defines homelessness as individuals who are rough sleepers, residents of emergency accommodation, and those living in insecure and inadequate housing (Amore et al., 2011). Based on that interpretation, there were 3808 persons homeless in Ireland in 2011 (Central Statistics Office, 2012). Homelessness is a growing concern as it has been shown that the prevalence is increasing in Ireland (Citizens Information Board, 2014, Edgar et al., 2003).
It is known that homelessness is associated with higher rates of mortality, morbidity, poor mental health, alcohol and drug use and other risky health behaviours relative to the general population (Central Statistics Office, 2012, Fazel et al., 2008, Hwang, 2001, Martens, 2001, O’Carroll and O’Reilly, 2008). Despite the volume of healthcare needs, homeless populations face a number of barriers to receipt of appropriate services (Canavan et al., 2012, Kushel et al., 2001).
Drug misuse in the homeless population has been identified as a significant risky behaviour and has been reported to be a cause, contributor and consequence of homelessness (Citizens Information Board, 2014, Lawless and Corr, 2005). Drug use is known to be more prevalent in the homeless population (O’Carroll and O’Reilly, 2008, Substance Abuse and Mental Health Services Administration, 2013), and studies have shown that it may be an increasing problem in this population (O’Carroll and O’Reilly, 2008). In surveys examining the prevalence of drug users among homeless population in Dublin, it was found between 29% and 64% were lifetime drug users and 26% to 41% were current users (Lawless and Corr, 2005). In the general population of Ireland approximately 1 in 5 (19%) have reported ever taking illicit drugs (National Advisory Committee on Drugs (NACD) and Drug and Alcohol Information and Research Unit (DAIRU), 2006 http://www.nacd.ie/images/stories/docs/publicationa/TechnicalReport_2002-3.pdf). Apart from alcohol, studies have reported cannabis, heroin, benzodiazepines, methadone, and head shop substances as the most frequent drug types used (Central Statistics Office, 2012).
A number of studies have examined the relationships between homelessness and the quality of life, mental health, and health service use of homeless people (Holohan, 2000, Keogh et al., 2015, O’Carroll and O’Reilly, 2008). Others have documented the negative effect of drug use on the quality of life (Costenbader et al., 2007, Fischer et al., 2005, Laudet et al., 2009, Millson et al., 2006, Ryan and White, 1996, Stein et al., 1998), physical health (most notably an increase in infectious diseases; Ezzati et al., 2002, Fischer et al., 2005, Ryan and White, 1996) and mental health (Beaulieu et al., 2012, Fischer et al., 2005, Ryan and White, 1996). However, it is not clear from the current literature how drug use affects the relationship between homelessness and these outcomes.
The aim of this study was to investigate whether drug use is associated with poorer physical health, higher levels of anxiety and/or depression, lower perceived quality of life in a homeless sample. A secondary aim of the study was to examine the levels of health service use, in particular Accident and Emergency (A&E) attendance, among homeless drug users when compared to other homeless groups.
Section snippets
Study design
The STROBE standardised reporting guidelines for cross-sectional studies were followed to conduct and report this study (von Elm et al., 2007). Ethical approval for this study was granted by the Royal College of Surgeons Research Ethics Committee.
Participants and setting
In Ireland, the majority of people pay to visit a GP and for their medication; around a third of the population is entitled to a means tested free healthcare scheme (GMS scheme). It is known from previous studies on the health of homeless people in
Participants
A total of 105 participants were recruited from the four clinics during the baseline recruitment period. Thirty-five (33%) were current users of illicit drugs, while 28 (27%) of participants had used drugs in the past, but reported no current drug use.
Demographics of drug users
Supplemental Table 11 displays the general demographics of all participants and the subset
Summary of main findings
This study found that a third of homeless people in this sample reported current illicit drug use. The majority of drug users were currently injecting one or more drugs, and the most common drug of choice was heroin. Current and previous drug users were five times more likely than non drug users to suffer from multimorbidity and current drug users were 4 times more likely compared to never drug users to have a lower perceived quality of life. Mental health problems were common in both groups
Role of the funding source
This work was supported by the Health Research Board (HRB) of Ireland through the HRB Centre for Primary Care Research under grant HRC/2007/1. Funding was also provided by RCSI Summer School (The Association of Physicians of Great Britain and Ireland, The Charitable Infirmary Charitable Trust and the Madeline Farrell Charitable Bequest). The funding source had no involvement in the study design, the collection, analysis or interpretation of data or writing the report.
Authors’ contributions
KOS, KOB, CK and TF conceived of the study and participated in its design. EDS, KOB and AS completed the data analysis. AS, AA, RG and KOB completed the first draft of the paper. All authors commented on the final manuscript.
Conflict of interest statement
AOC established Safetynet and facilitated our access to Safetynet clinics, however AOC was not involved in data collection, analysis or interpretation of the results. All other authors declare no competing interests.
Acknowledgements
We would like to thank the Safetynet staff, the staff at Merchants Quay Ireland, the Granby Centre, the Capuchin Centre and Beech House, as well as the 105 participants who took part in this study, without their help and expertise this project would not have been possible. We would also like to thank Janet Robinson, Jean Twohig, Michael Cronin, Anthony Hoban, Deirdre O’Connor and Muireann de Paor for their contribution to this project.
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