The abuse of alcohol and other drugs has long been recognized as a major factor contributing to the problems of the homeless. According to the National Coalition for the Homeless, in No Open Door: Breaking the Lock on Addiction Recovery for Homeless People (December 1998), the number of addictive disorders per capita within the homeless population is nearly twice that of the general population, and even higher in certain localities. The 2004 Conference of Mayors report estimated that 30% of homeless people in the twenty-seven cities surveyed were substance abusers.
Being intoxicated or high in public is considered socially unacceptable. Housed substance abusers have the luxury of staying out of public scrutiny when in such a condition. Homeless people, however, may have no place else to be except outside; many homeless shelters refuse to provide shelter to intoxicated persons. Consequently, homeless substance abusers are often more visible than those in the general population. In addition, studies published in the 1970s and 1980s often used lifetime rates of substance abuse, rather than current rates, and tended to focus on single, homeless men, which led to inflated statistics. The overall effect has been to create a false impression among many people that most or all of the homeless are drunks and drug addicts.
Young homeless people are at the greatest risk for substance abuse problems. Children, either in families or on their own, are the fastest-growing segment of the homeless population. In "Substance Use among Runaway and Homeless Youth in Three National Samples" (American Journal of Public Health, 1997), researchers J. M. Greene, S. T. Ennett, and C. L. Ringwalt found that 81% of street youth (children under eighteen who have been on their own for an extended period of time) and 67% of homeless youth in shelters were using alcohol. In addition, 75% of street youth and 52% of sheltered youth were using marijuana, and 26% of street youth and 8% of sheltered youth were using crack cocaine. Among housed youth, 64% used alcohol, 25% used marijuana, and 2% used crack cocaine.
Dual Diagnosis and Substance Abuse
The National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism report that mental illness and substance abuse frequently occur together; clinicians call this dual diagnosis. Experts state that in the absence of appropriate treatment, persons with mental illness often resort to "self-medication," using alcohol or drugs to silence the voices or calm the fears that torment them. Homeless people with dual diagnoses are frequently excluded from mental health programs because of treatment problems created by their substance abuse and are excluded from substance abuse programs due to problems in treating their mental illness. Experts explain that the lack of an integrated system of care plays a major role in their recurrent homelessness. They stress that transitional or assisted housing initiatives for homeless substance abusers must realistically address the issue of abstinence and design measures for handling relapses that do not place people back on the streets.
Welfare Reform and Substance Abusers
Some people fear that welfare policy changes have increased homelessness among impoverished people with addiction disorders. In 1996 Congress passed the Personal Responsibility and Work Opportunity Reconciliation Act (PL 104-193), which, among other things, denies Social Security Income and Social Security Disability Insurance benefits and, by extension, Medicaid to people whose addictions are a "contributing factor" in their disability. More than 200,000 people were affected by the cutoff. In "Welfare Reform and Housing: Assessing the Impact to Substance Abuse" (T. L. Anderson et al., Journal of Drug Issues, Winter 2002), the authors discussed their study of the effects of terminating the benefits to addicts "at a time of diminishing social services and a housing market explosion." Former benefit recipients reported increased homelessness and were found to be at increased risk of drug and alcohol use, criminal participation, and criminal victimization.