Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative

Background Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states. Design PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night. Results Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site’s adult population and were restricted to PWUD. Conclusions Our findings highlight that houselessness – historically considered an urban issue – is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery.

背景 在过去的二十年里，无家可归现象以及与毒品相关的流行问题都已从美国的城市地区蔓延到农村地区。然而，我们对农村无家可归、吸毒以及与毒品相关危害之间关系的理解却没有跟上步伐。当前的研究通过描述来自10个州农村社区的大量吸毒人群（PWUD）中的无家可归情况来填补这一空白。 设计 采用改良的链式推荐抽样法招募吸毒人群进行横断面调查，调查内容包括过去六个月的无家可归情况、吸毒情况、与毒品相关的危害、耻辱感、医疗服务获取情况以及社会人口学特征。通过双变量逻辑回归，我们评估了无家可归与参与者特征之间的关联。我们还将特定地点的无家可归流行率与住房和城市发展部的即时点数（PIT）估计值进行了比较，该估计值是基于某一晚有庇护和无庇护的无家可归者的数量。 结果 在3000名吸毒人群中，53.7%的人报告有无家可归的经历。无家可归与多种增加过量用药和感染血源性疾病风险的与毒品相关的行为有关。在几个地点，无家可归的流行率与即时点数估计值相当，甚至超过了该估计值，尽管研究参与者占每个地点成年人口的比例不到1%，且仅限于吸毒人群。 结论 我们的研究结果强调，无家可归——历史上被视为一个城市问题——是农村地区吸毒人群的一个重大公共卫生问题。这表明，要解决美国农村地区与毒品相关的艾滋病、丙型肝炎和过量用药等流行问题，需要提供稳定的住房和减少危害的服务，以此作为治疗和康复的途径。