RESEARCH AND PRACTICE Project-Based Housing First for Chronically Homeless Individuals With Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories Susan E. Collins, PhD, Daniel K. Malone, MPH, Seema L. Clifasefi, PhD, Joshua A. Ginzler, PhD, Michelle D. Garner, MSW, PhD, Bonnie Burlingham, MPH, Heather S. Lonczak, PhD, Elizabeth A. Dana, MA, Megan Kirouac, BS, Kenneth Tanzer, BA, William G. Hobson, MA, G. Alan Marlatt, PhD, and Mary E. Larimer, PhD A review of 29 studies conducted worldwide Objectives. Two-year alcohol use trajectories were documented among estimated an alcohol dependence prevalence of residents in a project-based Housing First program. Project-based Housing First 1 37.9% among homeless populations. Among provides immediate, low-barrier, nonabstinence-based, permanent supportive chronically homeless individuals (i.e., people with housing to chronically homeless individuals within a single housing project. The long-term, often-repeated episodes of homeless- study aim was to address concerns that nonabstinence-based housing may ness2), the prevalence of alcohol dependence enable alcohol use. is even higher.3 Alcohol dependence is associ- Methods. A 2-year, within-subjects analysis was conducted among 95 chron- ated with greater levels of alcohol problems, ically homeless individuals with alcohol problems who were allocated to project- resulting from acute intoxication or long-term based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records. alcoholuse,aswellasincreasedriskforalcohol- Results. Multilevel growth models indicated significant within-subjects de- related deaths.4 --- 7 creases across alcohol use outcomes over the study period. Intervention Unfortunately, traditional housing infra- exposure, represented by months spent in housing, consistently predicted structures designed to serve chronically additional decreases in alcohol use outcomes. homeless individuals with alcohol problems Conclusions. Findings did not support the enabling hypothesis. Although the often fail to engage residents and comprehen- project-based Housing First program did not require abstinence or treatment sively address their complex needs.8,9 One attendance, participants decreased their alcohol use and alcohol-related prob- reasonforthisfailuremightbeperceivedbar- lems as a function of time and intervention exposure. (Am J Public Health. 2012; riers to housing imposed by housing agencies, 102:511–519. doi:10.2105/AJPH.2011.300403) such as requiring psychiatric or substance abuse treatment attendance or abstinence from sub- stance use.10 Policymakers have therefore called receiving increased interest in the supportive nonabstinence-based housing approaches, such for the development of low-barrier housing pro- housing field,16 only a couple of studies to date as project-based Housing First, are appropriate grams that might more effectively engage these have examined their effectiveness in this pop- for chronically homeless individuals with alcohol individuals, house them, and attend to their ulation.13,17 These studies have shown that pro- problems.22 needs.11,12 ject-based Housing First programs are associated The argument for abstinence-based ap- Housing agencies have begun to respond to with increased housing stability, reduced use of proaches is typically derived from the disease this call by designing project-based Housing publicly funded services and associated costs, model of alcohol use disorder etiology, which First approaches to fit the specific needs of and short-term reductions in typical daily alcohol conceptualizes alcohol dependence as a chronically homeless individuals with alcohol use.13,17 “chronic, relapsing brain disease.”23,24 Propo- problems.13 As in other Housing First ap- Despite encouraging initial findings for the nents of the disease model posit that alcohol proaches (e.g., scattered-site Housing First), pro- project-based Housing First approach,13 absti- dependence should be treated through inter- ject-based Housing First for this population nence-based programs are the mainstay of ventions designed to help people achieve and entails the provision of low-barrier, nonabsti- housing models in the United States.18 Alcohol maintain abstinence.24 The corollary is that by nence-based (i.e., not requiring abstinence from abstinence and abstinence-based treatment re- not prohibiting alcohol use and by supporting substance use), immediate, and permanent quirements are typical across a wide range of clients’ choices about their drinking goals, non- housing.14,15 Specific to the project-based housing models (e.g., emergency shelters, transi- abstinence-based approaches may “enable” or Housing First model, however, individuals are tional housing, halfway houses, permanent sup- facilitate continued, harmful drinking.25 Despite offered units within a single housing project, portive housing).19 Even as Housing First models this widespread belief, there is little empirical where they can elect to receive on-site case are being recommended as evidence-based data to support it. Recent studies have shown management and other supportive services. Al- best practice12 and are receiving more attention that abstinence-based housing is not neces- though project-based Housing First programs are in the press,20,21 debate continues about whether sarily more effective than Housing First March 2012, Vol 102, No. 3 | American Journal of Public Health Collins et al. | Peer Reviewed | Research and Practice | 511 RESEARCH AND PRACTICE approaches26,27 and have indicated that clients still wished to participate either completed the a dummy-coded covariate to parallel previous and providers prefer the autonomy and sense baseline assessment immediately or were analyses13 and to account for the effects of data of stability of Housing First over traditional scheduled for subsequent appointments. missingness on overall modeling of alcohol use housing models.28,29 Research staff obtained written, informed outcomes in a group that experiences higher The study aim was to address concerns consent at baseline and verbally administered mortality attributable to conditions related to about the appropriateness of project-based the questionnaires described here as part of alcohol dependence.6 Housing First designed for chronically home- a larger questionnaire battery. Research staff Illness burden was assessed at the baseline less individuals with alcohol problems. Specif- were trainees in social sciences fields, were interview with the 19-item Medical Health ically, we tested the enabling hypothesis,25,30 required to attend a training session prior to Form.13 Participants reported on the presence or which posits that the provision of nonabsti- conducting interviews, and were supervised by absence of various medical disorders known to nence-based Housing First would result in the research coordinator and research investi- be common among chronically homeless indi- stable or increasing levels of alcohol use and gators (including licensed clinical psycholo- viduals with alcohol problems (e.g., HIV, tuber- alcohol-related problems. We predicted that gists). Research staff paid participants $20 for culosis, hepatitis). Items were summed to gener- the enabling hypothesis would not be con- each data collection interview, which occurred ate an illness burden score. This measure was firmed and that participants in project-based at baseline and 3-, 6-, 9-, 12-, 18-, and 24- found to be reliable in this sample (Kuder- Housing First would, on the contrary, show month follow-ups. Richardson statistic of internal consistency for significant, within-subjects decreases in alco- When housing turnover occurred, research dichotomous items=0.70). hol use and alcohol-related problems over a staff recruited control participants into the Outcome variables. The Alcohol Use Quantity 2-year follow-up. housing project according to their order on the Form was modified from the Timeline Follow- wait list. Control participants who moved into back for use with this population.13,31 This METHODS a housing unit during the first 3 months of measure was used at each interview and yielded study enrollment were reassigned to the in- alcohol quantity on typical and peak drinking The follow-up study reported here was a 2- tervention group in the parent study (n= 20) occasions in the past 30 days (referred to as year expansion upon initial findings discussed and were included in the follow-up study typical and peak quantity). Frequencies of alco- in a previous article.13 Data were collected in the (n=95). The remaining wait-list control hol use and drinking to the point of intoxication context of a nonrandomized controlled trial participants were not systematically assessed in the past 30 days were ascertained with comparing the effects of project-based Housing after the first 9 months because many moved items from the Addiction Severity Index.32 First and a wait list control condition on public into the Housing First project or other housing These 2 items were dummy-coded in the final system use and associated costs (details of the as it became available. Because complete 2- analysis to yield 30-day reports of at least 1 design, methods, and findings of the parent study year data were available for the intervention abstinent day and at least 1 day not drinking to are available in the initial report13). group alone, analyses reported here only in- intoxication. volve intervention participants. Alcohol-related