Substance use and homelessness: A longitudinal interview study conducted during COVID-19 with implications for policy and practice.

People who are homeless and using substances frequently encounter barriers to accessing support. This paper aims to inform policy and practice by analysing changes in the tobacco, alcohol and illicit drug use of people experiencing homelessness. Data derive from a qualitative longitudinal study (undertaken 2020/2021) and involving telephone interviews (n = 310) conducted with 34 people accommodated in two London hotels provided as part of a UK policy response to COVID-19. The hotels offered various supports, including opioid replacement therapy, prescribed alcohol, licensed nicotine replacement therapy, and e-cigarettes. Participants' substance use data were organised by Iterative Categorization and subjected to a content analysis to identify patterns and themes.. At entry to the hotel, 5/34 participants (14.7%) had never used alcohol nor illicit drugs; 10/34 (29.4%) had only ever used alcohol (mostly without a problem); 11/34 (32.4%) had ever used illicit drugs but without a problem; and 8/34 (23.5%) had ever had a problem with illicit drugs. Sub-groups had different socio-demographic characteristics, particularly regarding being/not being a UK national, sex, and homelessness duration. Tobacco smoking was common across all sub-groups (18/34; 52.9%). Participants were often anxious about living with others who were using substances, and some worried about their own substance use. Substance use was changeable, with more decreases than increases. Changes related to intrapersonal (psychological), interpersonal (social) and structural (resource-based) factors. For example, decreases were precipitated by people feeling motivated to change, separation from others who used drugs, and receiving treatment or support. Findings indicate that various interventions and accommodation models may benefit people who are homeless and using substances. An initiative that combined shelter and basic amenities, pharmacological treatment, psychosocial support, and space where substances were not available and other people using substances could be avoided resulted in an overall reduction in substance use amongst those accommodated.

Copyright © 2022. Published by Elsevier B.V.

Declarations of Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: In the last three years, J.N. has received, through her university, research funding from Mundipharma Research Ltd and Camurus AB (for unrelated research) and an honorarium from Indivior (for an unrelated conference presentation). S.P. is part-funded by income from research grants obtained from MundiPharma Research Ltd and Camurus AB. N.M. has received, through her university, research funding from Mundipharma Research Ltd (for unrelated research). She has also received, through her university, consultancy payment from an agency for Mayne Pharma International (also unrelated to the article under consideration). E.R. is employed by the South London and Maudsley (SLaM) NHS Foundation Trust and, from April 2020 until January 2021, worked as the clinical lead for the Homeless Hotel Drug and Alcohol Service (HDAS-London). He additionally holds an honorary employment contract at the Office of Health Improvement and Disparities (OHID) at the Department of Health and Social Care (DHSC), UK. In the last three years, J.S. has received, through his university, research funding from Mundipharma Research Ltd, Camurus AB, Accord Healthcare and Pneumowave (all for unrelated research). L.H. and D.R. report no competing interests.