Why I stand firm against the idea of "Safe" Consumption Tiny Homes

Some Facts

• Opioid Use Disorder is a chronic, potentially fatal condition, that limits one's ability to make thoughtful decisions regarding drug use.[1]

• Those struggling with Opioid Use Disorder AND are experiencing homelessness, are up to 12 times more likely to die from overdose, compared to the general population. Many with Opioid Use Disorder have other physical and mental health challenges, further amplifying their risk.[2][3][4][5][6][7][8]

• Any receipt of Medications for Opioid Use Disorder (MOUD) a.k.a. Opioid Agonist Therapy (OAT) reduces mortality risk, with sustained treatment conferring substantial additional benefit and discontinuation reversing these gains.[9]

• The Department of Veterans Affairs and Department of Defense Clinical Practice Guidelines strongly recommend Medications for Opioid Use Disorder as first-line treatment. The Guidelines go on to explicitly state that psychosocial treatment without medication is ineffective. Other research conducted to date aligns with this stance.[10][14][15]

• The social support model called "Housing First," (a rights-based [not needs based] intervention rooted in the idea that all people deserve housing, and that adequate housing is a precondition for recovery), is not associated with improved substance abuse or mental health outcomes. Despite widespread adoption, the research to date suggests that Housing First has not demonstrated decreased mortality among persons experiencing homelessness. In one study, participants were assigned to either Treatment as Usual, or in the Housing First group. Among Housing First participants, 39% of deaths occurred within the first 6 months following entry into housing. In contrast, the rate was just 18% in the Treatment as Usual group.[11][12]

• In the same study, those in the Housing First group were followed by a multidisciplinary support team, consisting of a psychiatrist, doctor, nurse, social worker, and peer worker, and followed an Assertive Community Treatment model, focusing on a recovery-oriented approach. Participants to staff numbered 10:1. In the Treatment as Usual group, homeless individuals received usual care, namely referrals to pre-existing dedicated homeless-targeted programs and services. Participants also had some interaction with outreach teams, shelters, and day-care facilities.[12]

• Concerns regarding the appropriateness of psychosocial approaches like Housing First for those living with significant substance use challenges are not new. Research done as early as 2009 (predating the modern fentanyl crisis) suggested strongly that generalizing Housing First to populations with addiction could create unintended harm. Calls for research to determine safety and define best practices were suggested before advocating for Housing First as a widespread form of support. Since then, a state of emergency has been declared in BC, and opioid overdose deaths have reached historically high levels. Housing First models that incorporate safe consumption service models have been broadly implemented despite lacking evidence for reduced mortality.[13]

• These results should force us to consider whether such housing models, implemented in this fentanyl era, and without Opioid Agonist Therapy, are even remotely ethical or reflect best practices, person-centered care. As a single exposure to even tiny amounts of fentanyl can be fatal, ignoring the thinking impairments associated with opioid use disorder is essentially to abandon the needs of the client, under the guise of "respecting client autonomy." Other medical and psychiatric conditions characterized by executive functioning deficits require structured supports that actively reduce risk; Housing First advocates instead seem to champion a passive tolerance of risk.

• Methadone has been in Canada since 1964, for the treatment of Opioid Use Disorders, and buprenorphine was similarly approved for use in 2007. Research examining hundreds of thousands of participants have consistently demonstrated that Opioid Agonist Therapy is the first-line, and the most effective treatment for Opioid Use Disorder, both in North America, and in many other countries.[14][15]

• Utilizing case managers skilled in motivational interviewing, psychotherapy, and abstinence-based contingency management, alongside Opioid Agonist Therapy could significantly improve treatment engagement and survival.[16]