“You just want to kill the pain and get numb:” A mixed methods study investigating the lived experiences of individuals experiencing homelessness enrolled in outpatient methadone treatment

Background

People experiencing homelessness (PEH) with opioid use disorder (OUD) are at high risk of overdose yet less likely to enroll and stay engaged in standard-of-care treatment for OUD, opioid agonist medication for OUD (MOUD), particularly methadone treatment. Engaging this group in treatment is a public health priority, yet little is known about the experiences of PEH enrolled in MOUD. We sought to understand the housing experiences and perspectives of PEH engaged in methadone treatment using mixed quantitative and qualitative methods.

Methods

We recruited individuals with past or present experiences of homelessness who were engaged in methadone treatment at a low-barrier opioid treatment program (OTP) in Connecticut between December 2022 and May 2023. Participants completed surveys about their demographics, resource needs, and housing and healthcare experiences. One-to-one qualitative interviews using a semi-structured interview guide queried participants' experiences with homelessness. Descriptive statistics summarize study variables using Python. The interviews were transcribed and analyzed using thematic analysis.

Results

Of 50 participants (19 women, 31 men, mean age 44 years), 80 % reported experiencing homelessness for over a year. Participants reported experiencing a mean of 56.6 months without permanent, stable housing and a mean of 2.4 periods of homelessness in the past 3 years. Thematic analysis yielded three primary themes that described the intersectional identity of an individual with OUD and experiencing homelessness: 1) Challenges created by homelessness (e.g., transportation barriers limiting access to the OTP); 2) Personal barriers to exiting homelessness (e.g., struggling with continued substance use); and 3) Structural barriers to exiting homelessness (e.g., difficulty navigating the housing system).

Conclusions

PEH enrolled in methadone treatment face substantial barriers related to their OUD and housing status as well as many structural, social, and health-related vulnerabilities. Future efforts to address these vulnerabilities in clinical settings may enhance treatment engagement and should be examined to potentially attenuate the very high risk of overdose that PEH face. Challenges created by homelessness, personal barriers to exiting homelessness, and structural barriers to exiting homelessness are potential targets for methadone treatment programs to better tailor treatment and improve engagement and outcomes.