By Scarlet Neath,  Rashad James,  Charlotte Resing, 

Nationally, at least 12% of all police arrests are for possessing, selling, or making illicit drugs. Despite using and selling illicit drugs at similar rates as White people do, Black people are more likely to be arrested, incarcerated, and reported to law enforcement by medical professionals for substance use. Decades of criminalizing certain substances as a crime-control tactic has failed to achieve its goal of eliminating drug use and instead contributed to profound stigma and fear of punishment that prevents people from accessing treatment and support. It has also resulted in the proliferation of smaller, more potent versions of illicit drugs–like fentanyl–which have exacerbated the opioid crisis in recent years. In 2021, drug overdose deaths reached a record high of 106,699 people, and overdose from synthetic opioids such as fentanyl is now a leading cause of death for adults ages 18 to 45. Because of systemic inequities, including in health care access and the criminal legal system, Black and Native people are experiencing even higher increases in overdose rates than White people are. A public safety approach to substance use, in contrast, means ending the widespread, racist, arbitrary, and ineffective 

criminalization of certain drugs. It requires fully investing instead in equitable and accessible systems of care to prevent and reduce the harms associated with substance use, including consistently offering services that recognize continued, moderated use as a common and acceptable feature of recovery. Laws prohibiting the use of certain drugs (including alcohol at one time) have been repeatedly enacted, fueled by racist narratives about the dangerous behavior of particular groups of people due to their substance use, including German, Irish, and Chinese immigrants; Black men; and communists. The Controlled Substances Act of 1970 created the current framework stipulating which substances are deemed illicit under federal law. It also established categories for regulating substances based on the perception about potential for abuse and whether the substance has any medical benefits. Notably, alcohol and tobacco were excluded despite high potential for dependency. The enforcement of drug laws increased dramatically after 1971, when President Nixon declared the war on drugs,10 which an advisor later said was an effort to criminalize and vilify Black people and war protesters. After this announcement, the government embarked on a decades-long trend of prioritizing and increasing funding for enforcement that is still ongoing. For example, the U.S. government spent approximately $2.8 billion on drug enforcement in 1981, adjusted for inflation, compared to $19.3 billion in 2023. This immense federal funding has enabled wide and inequitable enforcement of drug laws by local law enforcement agencies, funneling millions of people–especially Black and Latino men–into carceral systems and saddled them with criminal records that affect their future eligibility for housing, employment, voting, and education while undermining community health In 2022, law enforcement made more than 600,000 arrests for drug possession nationally. Black people are almost twice as likely as White people to be arrested for drug offenses. The war on drugs is widely recognized as a primary contributor to mass incarceration, racial disparities in incarceration rates, and militarized policing tactics. .From 1980 to 2011, the average federal prison sentence for a drug offense increased 36%, and similarly, the state incarceration rate for drug offenses increased nearly tenfold.  As of 2019, Black people were 3.6 times more likely than White people to be incarcerated in state prisons for a drug offense.  In addition to being a primary driver of mass incarceration, these efforts have failed to eliminate drug use–and its associated harms–from our society. Instead, over the past several decades of heavy enforcement, illegal drug prices have declined and the annual number of overdose deaths has risen fivefold since 1999. From 2019 to 2020, the latest year of data, drug overdose rates rose 22% among White people, 39% among Native people, and 44% among Black people. These disparities are not fully explained by differences in substance use patterns. Instead, Black communities face heightened barriers to accessing care due to reasons including criminalization, mistrust of the medical system, and lack of access to certain evidence-based treatments.  According to recent data, Black people who died from overdose had the lowest rate of previous substance use treatment.

West Hollywood, CA: Center for Policing Equity , 2024. 40p. 

By Chris O'Leary, Rob Ralphs, Jennifer Stevenson, Andrew Smith, Jordan Harrison, Zsolt Kiss, Harry Armitage

Background

Homelessness is a traumatic experience, and can have a devastating effect on those experiencing it. People who are homeless often face significant barriers when accessing public services, and have often experienced adverse childhood events, extreme social disadvantage, physical, emotional and sexual abuse, neglect, low self-esteem, poor physical and mental health, and much lower life expectancy compared to the general population. Rates of problematic substance use are disproportionately high, with many using drugs and alcohol to deal with the stress of living on the street, to keep warm, or to block out memories of previous abuse or trauma. Substance dependency can also create barriers to successful transition to stable housing.

Objectives

To understand the effectiveness of different substance use interventions for adults experiencing homelessness.

Search Methods

The primary source of studies for was the 4th edition of the Homelessness Effectiveness Studies Evidence and Gaps Maps (EGM). Searches for the EGM were completed in September 2021. Other potential studies were identified through a call for grey evidence, hand-searching key journals, and unpacking relevant systematic reviews.

Selection Criteria

Eligible studies were impact evaluations that involved some comparison group. We included studies that tested the effectiveness of substance use interventions, and measured substance use outcomes, for adults experiencing homelessness in high income countries.

Data Collection and Analysis

Descriptive characteristics and statistical information in included studies were coded and checked by at least two members of the review team. Studies selected for the review were assessed for confidence in the findings. Standardised effect sizes were calculated and, if a study did not provide sufficient raw data for the calculation of an effect size, author(s) were contacted to obtain these data. We used random-effects meta-analysis and robust-variance estimation procedures to synthesise effect sizes. If a study included multiple effects, we carried out a critical assessment to determine (even if only theoretically) whether the effects are likely to be dependent. Where dependent effects were identified, we used robust variance estimation to determine whether we can account for these. Where effect sizes were converted from a binary to continuous measure (or vice versa), we undertook a sensitivity analysis by running an additional analysis with these studies omitted. We also assessed the sensitivity of results to inclusion of non-randomised studies and studies classified as low confidence in findings. All included an assessment of statistical heterogeneity. Finally, we undertook analysis to assess whether publication bias was likely to be a factor in our findings. For those studies that we were unable to include in meta-analysis, we have provided a narrative synthesis of the study and its findings.

Main Results

We included 48 individual papers covering 34 unique studies. The studies covered 15, 255 participants, with all but one of the studies being from the United States and Canada. Most papers were rated as low confidence (n = 25, or 52%). By far the most common reason for studies being rated as low confidence was high rates of attrition and/or differential attrition of study participants, that fell below the What Works Clearinghouse liberal attrition standard. Eleven of the included studies were rated as medium confidence and 12 studies as high confidence. The interventions included in our analysis were more effective in reducing substance use than treatment as usual, with an overall effect size of –0.11 SD (95% confidence interval [CI], −0.27, 0.05). There was substantial heterogeneity across studies, and the results were sensitive to the removal of low confidence studies (−0.21 SD, 95% CI [−0.59, 0.17] − 6 studies, 17 effect sizes), the removal of quasi-experimental studies (−0.14 SD, 95% CI [−0.30, 0.02] − 14 studies, 41 effect sizes) and the removal of studies where an effect size had been converted from a binary to a continuous outcome (−0.08 SD, 95% CI [−0.31, 0.15] − 10 studies, 31 effect sizes). This suggests that the findings are sensitive to the inclusion of lower quality studies, although unusually the average effect increases when we removed low confidence studies. The average effect for abstinence-based interventions compared to treatment-as-usual (TAU) service provision was –0.28 SD (95% CI, −0.65, 0.09) (6 studies, 15 effect sizes), and for harm reduction interventions compared to a TAU service provision is close to 0 at 0.03 SD (95% CI, −0.08, 0.14) (9 studies, 30 effect sizes). The confidence intervals for both estimates are wide and crossing zero. For both, the comparison groups are primarily abstinence-based, with the exception of two studies where the comparison group condition was unclear. We found that both Assertative Community Treatment and Intensive Case Management were no better than treatment as usual, with average effect on substance use of 0.03 SD, 95% CI [−0.07, 0.13] and –0.47 SD, 95% CI [−0.72, −0.21] 0.05 SD, 95% CI [−0.28, 0.39] respectively. These findings are consistent with wider research, and it is important to note that we only examined the effect on substance use outcomes (these interventions can be effective in terms of other outcomes). We found that CM interventions can be effective in reducing substance use compared to treatment as usual, with an average effect of –0.47 SD, 95% CI (−0.72, −0.21). All of these results need to be considered in light of the quality of the underlying evidence. There were six further interventions where we undertook narrative synthesis. These syntheses suggest that Group Work, Harm Reduction Psychotherapy, and Therapeutic Communities are effective in reducing substance use, with mixed results found for Motivational Interviewing and Talking Therapies (including Cognitive Behavioural Therapy). The narrative synthesis suggested that Residential Rehabilitation was no better than treatment as usual in terms of reducing substance use for our population of interest.

Authors' Conclusions

Although our analysis of harm reduction versus treatment as usual, abstinence versus treatment as usual, and harm reduction versus abstinence suggests that these different approaches make little real difference to the outcomes achieved in comparison to treatment as usual. The findings suggest that some individual interventions are more effective than others. The overall low quality of the primary studies suggests that further primary impact research could be beneficial.

Campbell Systematic Reviews, Volume 20, Issue , June 2024, 65 pages