Abstract
Harm reduction services save lives and facilitate treatment uptake for people who are unhoused and use drugs. It is unknown whether provision of harm reduction services within a transitional housing environment affects treatment uptake, drug supply, or drug using behaviors. This study focused on mitigation of the impacts of mass relocation and uptake of services by residents of harm reduction housing (HRH) to generate novel insights on individual drug use, social cohesion, collective efficacy, and health outcomes resulting from HRH. We used a mixed-methods study leveraging our prior Rapid Assessment of Consumer Knowledge findings and ongoing drug checking capacity to gather data on response to rapid rehousing in Boston’s “Mass and Cass” neighborhood. First, we developed an inventory of harm reduction services offered and accessible to HRH residents to sufficiently measure exposure. Second, we launched an observational cohort following 106 HRH residents at 2 time periods over 12 months. Finally, we invited a subset of 28 cohort members to take part in repeated, longitudinal one-on-one interviews to gain greater insight into HRH, development of social cohesion and collective efficacy, and drug-related outcomes. Protocol adaptations due to housing shifts, over policing, and serendipity were applied.
Highlights
This study protocol examines the implementation and resident experiences in harm reduction housing (HRH) locations.
A harm reduction approach is needed to effectively address cooccurring substance use disorder and homelessness.
Through surveys, longitudinal interviews, drug checking, photography, and clinical data linkage, the unique approach and impacts of HRH are explored and may be adapted in other settings.
Introduction
Across cities and towns in the United States, the COVID-19 pandemic strained an ongoing housing crisis, leaving unprecedented numbers of people experiencing homelessness (PEH) and creating poor health conditions in precarious, concentrated homeless encampments.1,2 Over the past 5 years, the growing homeless population in cities has witnessed infectious disease outbreaks such as hepatitis A and HIV.3,4 Substance use disorder, both a driver and a consequence of homelessness, is a chronic cooccurrence that, in the age of fentanyl and other synthetic drugs, generates complex and unsettling statistics: Drug overdose is a leading cause of morbidity and mortality for PEH.5-7 The mounting syndemic of homelessness, infectious diseases, addiction, and a toxic illicit drug supply 8 has led to a range of responses: Some cities conduct police-led “sweeps” of tent encampment areas; others call in the National Guard for maintaining public order; some threaten to or arrest PEH sleeping in public settings; in Boston, Massachusetts, a public health emergency declaration led to coupled actions of tent encampment clearings, relocation, and transitional housing placement.
Unlike past efforts to address concentrated homelessness, 9 Boston’s housing initiative took a low-barrier shelter and housing model approach, termed harm reduction housing (HRH). Harm reduction services save lives and facilitate treatment uptake for PEH who use drugs. 10 HRH incorporates harm reduction principles and directly addresses social determinants of health.
Research indicates that disruption of encampments can harm inhabitants, but may be mitigated by concerted efforts to address risks, including provision of alternative housing like HRH.11,12 Thus, the Boston, MA, example stood out, as it addresses homelessness as part of a comprehensive overdose response, and motivated the proposed study of the impact of this alternative approach.
HRH sites in this study were low-threshold transitional housing locations, inspired by models like supportive housing and Housing First program initiatives and successes with low-barrier housing for people with COVID infection. 13 HRH differs from traditional Housing First, permanent housing programs because they are transitional spaces that simultaneously colocate harm reduction services and supplies. Traditional housing interventions like Housing First incorporate harm reduction inconsistently, if at all,14,15 leaving a major gap in knowledge and practice in this field. The HRH sites in Boston comprise a network of supportive housing hotels and temporary “cottage” structures providing transitional housing without requiring abstinence and supporting residents who use drugs by proactively providing them regular access to supplies for safer use and peer response like naloxone, low-barrier medication treatment, prevention services like preexposure prophylaxis and postexposure prophylaxis for HIV, and connection to peer support. Some HRH sites provide services via mobile health units or remote teams who visit sites regularly, while others offer services on-site. The ultimate goal of HRH sites for residents is to permanently house them, but slow placement necessitated longer HRH stays. While public resources are committed to HRH operations, support for this model over the long-term and by housing type (ie, converted shelters, single room occupancy) is uncertain. Beyond the HRH model, it is critical to thoroughly consider the role of solidarity, collective efficacy,16,17 autonomous actions by people who use drugs (PWUD), 18 and peer involvement in mitigating risks of major transitions like forced relocations. Thus, our study capitalized on a critical window of relocation and stabilization of this important and vulnerable population when supports were put in place, to rapidly examine HRH sites, better define their model, and document their effects on resident drug use, peer interactions, housing experiences, HIV risk, and well-being, from the perspective of their residents and staff.
Study Aims
Funded by the National Institute on Drug Abuse, the current observational study set out to examine HRH operations and resident experiences in Boston between 2023 and 2025. The first aim developed an inventory through interviews with HRH staff and site-specific ethnographic observations to assess availability, awareness, and uptake of harm reduction services at HRH sites. The second aim explored via a quantitative survey instrument, how relocating individuals into HRH sites affected drug use, HIV, and overdose risk behaviors. The third aim conducted longitudinal interviews at baseline, 3, and 6 months with cohort members on their perceptions of relocation, HRH, and explore the potential role in risk reduction of peer interactions and collective efficacy, meaning how community’s shared belief systems work together to achieve common goals and maintain safety and order, 19 over time in the sites.
Study Design
Defining HRH Elements
This study involved 7 HRH sites operating within the Boston area, which were expected to change and possibly cease operating during the study period. There were a variety of HRH models within our study: 3 sites were transformed from shelter spaces, 3 spaces were converted hotels or office space, and 1 space was a tiny house “cottage” model. We established partnerships with HRH sites and their program directors to facilitate multiple in-person site visits for data collection. Taking a stepped approach to measurement design, first literature was reviewed to generate characteristics that define HRH. Then, qualitative interviews with HRH program staff were conducted to elicit first-hand experiences regarding HRH and operational aspects of the sites. Program staff were compensated with $25 gift cards. Simultaneously, site visits and observational field notes supplemented interview insights with physical attributes of HRH locations. Synthesizing across data sources, we compiled a working inventory of essential, common elements of HRH that could be administered to both staff and residents.
HRH Residents Cohort
This protocol builds on the formative work of the Mass and Cass Rapid Assessment of Consumer Knowledge (RACK) study,20-25 which assisted in the following: (1) recruitment synergies, (2) measurement development, and (3) logistical and data efficiencies. First, we invited eligible individuals who participated in the prior Mass and Cass RACK Study and consented to be recontacted, which sped study enrollment. In addition, relationships with HRH sites and community programs from prior studies allowed for responsive enrollment and effective recruitment during ongoing outreach. Second, we streamlined previous survey measures to focus explicitly on HRH experiences and confidently adopted items previously administered to the study population. Third, we implemented previously successful logistical and study procedures, including the following: collecting data using the Computer Assisted Personal Interviewing software (Qualtrics.com, Provo, UT), administering assessments with trained staff on a tablet or laptop in a private space (established both near the Mass and Cass area at Boston Medical Center or at the HRH site), compensating in cash ($40) for the 60-minute assessment, and providing Spanish language interview options. We also populated the consenting cohort with retrospective data by leveraging responses from previously enrolled RACK participants to efficiently create a cohort of people experiencing housing instability, relocation, and HRH residence.
After confirmation of recruitment sites and IRB approval of the protocol (see Supplemental Material), research staff enrolled 106 eligible HRH residents into a 12-month observational cohort study. The primary outcomes include the uptake of harm reduction supplies and services, drug use behaviors, overdose experiences, medications for opioid use disorder (MOUD) treatment engagement, HIV-related outcomes, and drug supply characteristics. Both self-report and, with consent, medical record data contributed to outcome ascertainment. As pioneered in prior RACKs, remnant drug samples from each individual were collected prospectively (baseline, 12-month follow-up) and subsequently linked to prior sample submissions, along with current and past self-reported assessments, clinical records, and housing data.
Drug Checking
An important component of the study included collecting remnant drug samples (eg, once used cookers or residue from baggies) from consented participants, in exchange for additional compensation. 26 Participants were invited to submit up to 3 samples for analysis. Remnant drug samples were collected and examined by research staff for visible residue then stored in plastic bags, cataloged, and labeled with a unique study identification number. Samples were logged into StreetCheck.org, a web app platform for managing drug checking, 27 and participants were asked questions about their samples (ie, where it was obtained, what they believed it to be, preparation, use experiences). Drug samples were subsequently tested by a trained drug-checking technician in accordance with standard operating procedures.28-30 Specifically, contents of the remnant sample were scraped out, scanned using an Fourier transformed infrared spectroscopy, tested using immunoassay test strips, then any remaining sample was mailed for further laboratory testing by gas chromatography–mass spectrometry. Results from collected samples were shared with the participant and also used for research purposes to gain insight into the drug supply in and around the HRH settings, longitudinally.
In-Depth, Longitudinal Interviews
Due to the dynamic nature of this area, its population, and the HRH sites, we sought to complement survey data with qualitative, longitudinal interviews with residents. We identified a subset of 28 cohort members across 6 HRH sites for one-on-one, in-depth qualitative interviews, conducted at 3-month intervals (baseline, 3-, and 6-month follow-up). Study staff offered interviews to cohort members who were diverse in age, gender, and race. The interview was semi-structured, conducted by trained research staff, recorded and transcribed. Interviews spanned 45 to 90 minutes and participants were compensated in cash for baseline ($25), 3-month ($25), and 6-month ($40) follow-up interviews. The interviews were coded deductively and inductively to uncover emergent themes related to resident experiences.
Study Adaptations
This feasibility study presented several challenges and opportunities for adaptations. The study population included unstably housed individuals living in heavily policed areas of the city, who frequently transitioned between various settings including other HRH sites, permanent residences, and occasionally, back to the streets and non-HRH shelters. Many participants lacked consistent means of communication such as not having access to phone, Internet, or email. Consequently, maintaining contact for follow-up interviews proved challenging.
In efforts to reduce participant attrition, we engaged in the following activities: (1) more frequent visits to the HRH sites to stay in touch with participants, (2) regular collection of ethnographic observations documented through field notes to understand shifts in the community, (3) adding questions and probes to the longitudinal interviews about recent police sweeps and HRH site closures to learn how these actions have affected their day-to-day lives, and (4) commencing real-time, on-site drug checking at HRH sites. More specifically, we shifted to offering on-site, real-time drug checking in order to reduce burden on research staff, facilitate engagement from residents, and provide a meaningful service to HRH residents. Participants appreciated the service and the research team remained a resource for participant follow-up.
A formidable challenge arose when one of the HRH sites abruptly ceased and another began operations during the study. Although we had already collected valuable data from HRH staff at the site that closed, we had not yet included their residents in our cohort. As a result, we excluded the closed site from the scope of our investigation concerning aim 2. However, due to the importance of the site’s model and the novel insights it provided on HRH, we opted to keep it within the framework of aim 1. To ensure adequate representation from each site, we increased our recruitment efforts at the remaining sites and welcomed the new HRH site when it opened later on in our study.
A final serendipitous study adaptation involved inclusion of photographic data. Struck by the vibrant variety and expression of residents in HRH and the challenge of describing the sites in word alone, we opted to include photographic images of both communal and personal spaces within HRH sites to our data collection. Study staff obtained informed consent from residents to take photographs of personal space or individual rooms at HRH sites. Several photographs were open-coded 31 by research staff to derive an initial codebook. Photos were then coded by the study team (via Dedoose) 32 and codes were refined and discussed at weekly team meetings. Photographs were taken throughout the study period and were used to better understand the importance of collective efficacy, personal space, and autonomy within the context of low-barrier housing. This adaptation provided another perspective of how HRH residents experience and use the space within these housing locations. While we were able to obtain photographs of communal spaces at most HRH sites, only 4 sites allowed us to take pictures of resident’s personal spaces because some operated an open-floor plan rather than segmented personal spaces or individual rooms.
Future Directions
Taken together, this study and its adaptations will inform housing and harm reduction service provision and may uncover new intervention points for further investigation. Our study presents a methodology for producing a multifaceted, nuanced view of HRH in deriving data from several different mediums. The protocol is flexible, adaptable, and nuanced for examining individual behaviors, peer and social dynamics, drug supply characteristics, and clinical outcomes in an HRH environment. As cities and states enact responses to homelessness, future studies can draw from this protocol, the instruments developed, and the adaptations described to further our understanding of how HRH approaches are implemented, evolve, and are experienced. Such data will advance the science of harm reduction, contribute new tools to health services, and add critically needed evidence-based, humane relocation and housing crisis interventions to the possible responses policymakers can undertake. Finally, longitudinal studies of PEH placed in HRH should measure longer term housing and health outcomes and these data can inform cost-effectiveness analyses of HRH for a more comprehensive, comparative examination of this and alternative responses.
Supplemental Material
sj-pdf-1-saj-10.1177_29767342251341706 – Supplemental material for Study Protocol on Rapid Measurement of Novel Harm Reduction Housing on HIV Risk, Treatment Uptake, Drug Use, and Supply
Supplemental material, sj-pdf-1-saj-10.1177_29767342251341706 for Study Protocol on Rapid Measurement of Novel Harm Reduction Housing on HIV Risk, Treatment Uptake, Drug Use, and Supply by Traci C. Green, Joseph Silcox, Sofia Zaragoza, Charlie Summers, Sabrina Rapisarda, Sarah Kosakowski, Andrew Rolles, Avik Chatterjee, Alexander Walley, Miriam Komaromy and Patricia Case in Substance Use & Addiction Journal
Footnotes
Author Contributions
All authors contributed to the conception and writing of the manuscript. JS and TCG oversaw study implementation and wrote the initial draft. SR, SZ, AR, and CS conducted data collection and assisted with study adaptations. AC, PC, SK, MK, and AYW performed critical reviews, and collaborated with TCG and JS on manuscript revisions. TCG obtained the funding and designed the study. All authors approved the final manuscript and are responsible for the final content.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Insititute of Health (NIH) R21 DA058581.
Compliance,Ethical Standards,and Ethical Approval
Institutional review board approval was not required.
References
Supplementary Material
Please find the following supplemental material available below.
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