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Rural houselessness among people who use drugs in the United States
Results from the National Rural Opioid Initiative
Ballard, A. M., Kesich, Z., Crane, H. M., Feinberg, J., Friedmann, P. D., Go, V. F., Jenkins, W. D., Korthuis, P. T., Miller, W. C., Pho, M. T., Seal, D. W., Smith, G. S., Stopka, T. J., Westergaard, R. P., Zule, W. A., Young, A. M., & Cooper, H. L. (2024). Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative. Drug and Alcohol Dependence, 266, 112498. Advance online publication. https://doi.org/10.1016/j.drugalcdep.2024.112498
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.