October 21, 2010

Drug-Related Emergency Department Visits by People Experiencing Homelessness: 2006 to 2008

Physical and behavioral health problems are prevalent and often co-occur among people experiencing homelessness, contributing to both the causes of homelessness and to the other risk factors facing this population. The health problems of people experiencing homelessness are greatly aggravated by their lack of access to health care and medical insurance, lack of appropriate medical documentation, and transience. For people experiencing homelessness, substance abuse, physical and mental health problems, exposure to the elements, and street violence often converge, which may increase the need for emergency care.

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related ED visits in the United States. DAWN can be used to provide valuable information on the drug-related ED visits made by people experiencing homelessness. To be a DAWN case, the ED visit must have involved a drug, either as the direct cause of the visit or as a contributing factor. For each case, the patient's ZIP Code information was gathered; if no ZIP Code was available, data abstractors recorded whether the patient had no fixed address (i.e., was experiencing homelessness), lived in an institution, lived outside the United States, or had some other situation. Cases identified as having no fixed address are referred to as "persons experiencing homelessness" in this report.¹ This issue of The DAWN Report uses annual averages based on combined 2006 to 2008 data to focus on drug-related ED visits made by people experiencing homelessness; selected comparisons are made with other types of drug-related ED visits made by those who were not homeless.

Between 2006 and 2008, the annual estimate of drug-related ED visits made by persons experiencing homelessness was 59,310 visits. Most of these ED visits were made by males (71.9 percent) and persons aged 25 to 49 (72.0 percent). The majority of visits by people experiencing homelessness (62.9 percent) were made to publicly funded EDs rather than to private facilities. Among ED visits made by those who were not homeless, only 19.6 percent of visits were made to public facilities.

The majority of drug-related ED visits by people experiencing homelessness (73.5 percent) involved illicit drugs, compared with 23.5 percent of visits by those who were not homeless. Visits made by people experiencing homelessness were more likely than visits by those who were not homeless to involve cocaine (50.6 vs. 12.5 percent), heroin (19.6 vs. 4.5 percent), and marijuana (15.9 vs. 8.1 percent) (Figure 1). Conversely, visits by homeless persons were less likely than visits by their counterparts to involve central nervous system (CNS) drugs (14.2 vs. 34.3 percent), such as pain relievers and drugs to treat anxiety and insomnia. They were also less likely to involve psychotherapeutic drugs (3.9 vs. 8.2 percent) such as antidepressants and antipsychotics.

Figure 1. Selected Drugs Involved in Emergency Department (ED) Visits by People Experiencing Homelessness Compared with Visits by Those Who Were Not Homeless: 2006 to 2008

Combinations of alcohol with other drugs were involved in about one third (34.3 percent) of the visits by people experiencing homelessness compared with 15.3 percent of visits by those who were not homeless. Both of these percentages might underestimate alcohol-related visits because DAWN excludes visits involving only alcohol for patients aged 21 or older.

Drug-related ED visits among males experiencing homelessness were more likely than visits among females experiencing homelessness to involve alcohol (36.6 vs. 28.2 percent) and marijuana (17.7 vs. 11.2 percent) (Figure 2). However, the involvement of cocaine, heroin, psychotherapeutic drugs, and CNS drugs did not vary by gender.

Figure 2. Selected Drugs Involved in Emergency Department (ED) Visits by People Experiencing Homelessness, by Gender: 2006 to 2008

Following a drug-related ED visit, two fifths of people experiencing homelessness were treated and released (41.2 percent). Among those who were treated and released, three fourths (75.0 percent) were discharged, and one fifth (21.6 percent) were referred to detoxification or other substance use treatment (Figure 3). In contrast, among the vast majority of the population that was not homeless, more than two thirds (68.4 percent) were treated and released. Among those treated and released, 93.4 percent were discharged, and only 3.7 percent were referred to detoxification or other substance use treatment.

Figure 3. Disposition of Emergency Department (ED) Visits by People Experiencing Homelessness Who Were Treated and Released Compared with Those Who Were Not Homeless: 2006 to 2008

Thousands of people experiencing homelessness are seen in EDs each year for drug-related causes. From 2006 to 2008, most of these visits involved illicit drugs rather than pharmaceutical drugs; about half of the visits involved use of cocaine. EDs present a unique opportunity to identify members of this vulnerable population and assist them in finding longer-term medical care, housing, and recovery services. Additionally, ED personnel and social workers within the hospital can coordinate and connect these patients with medical respite, housing, and recovery programs, which have been shown to reduce future hospital utilization and can empower people experiencing homelessness to follow through with referrals to treatment. The links and coordination between medical providers and homeless assistance programs can help to ensure that the medical community is kept up to date on the spectrum of services in their community targeted to one of our country's most vulnerable populations.

This page was last updated on July 13, 2010.