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      Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness

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          This survey study examines the prevalence of and risk factors associated with nonfatal drug or alcohol overdose among veterans who have experienced homelessness.

          Key Points


          How common is nonfatal overdose among veterans who have experienced homelessness, and what are the risk factors and substances involved in overdoses?


          In this survey study including 5766 veterans nationwide who have experienced homelessness, 7.4% of veterans reported an overdose in the previous 3 years. Among veterans reporting overdose, alcohol was the most commonly involved substance.


          These findings suggest that nonfatal overdose is a relatively common issue among veterans who have experienced homelessness and one that warrants additional attention.



          Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose.


          To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness.

          Design, Setting, and Participants

          This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020.

          Main Outcomes and Measures

          Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records.


          A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose.

          Conclusions and Relevance

          These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

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          Most cited references 44

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             Margot Kushel (2001)
            Homeless persons face numerous barriers to receiving health care and have high rates of illness and disability. Factors associated with health care utilization by homeless persons have not been explored from a national perspective. To describe factors associated with use of and perceived barriers to receipt of health care among homeless persons. Secondary data analysis of the National Survey of Homeless Assistance Providers and Clients. A total of 2974 currently homeless persons interviewed through homeless assistance programs throughout the United States in October and November 1996. Self-reported use of ambulatory care services, emergency departments, and inpatient hospital services; inability to receive necessary care; and inability to comply with prescription medication in the prior year. Overall, 62.8% of subjects had 1 or more ambulatory care visits during the preceding year, 32.2% visited an emergency department, and 23.3% had been hospitalized. However, 24.6% reported having been unable to receive necessary medical care. Of the 1201 respondents who reported having been prescribed medication, 32.1% reported being unable to comply. After adjustment for age, sex, race/ethnicity, medical illness, mental health problems, substance abuse, and other covariates, having health insurance was associated with greater use of ambulatory care (odds ratio [OR], 2.54; 95% confidence interval [CI], 1.19-5.42), inpatient hospitalization (OR, 2.60; 95% CI, 1.16-5.81), and lower reporting of barriers to needed care (OR, 0.37; 95% CI, 0.15-0.90) and prescription medication compliance (OR, 0.35; 95% CI, 0.14-0.85). Insurance was not associated with emergency department visits (OR, 0.90; 95% CI, 0.47-1.75). In this nationally representative survey, homeless persons reported high levels of barriers to needed care and used acute hospital-based care at high rates. Insurance was associated with a greater use of ambulatory care and fewer reported barriers. Provision of insurance may improve the substantial morbidity experienced by homeless persons and decrease their reliance on acute hospital-based care.
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              An improved diagnostic evaluation instrument for substance abuse patients. The Addiction Severity Index.

              The Addiction Severity Index (ASI) is a structured clinical interview developed to fill the need for a reliable, valid, and standardized diagnostic and evaluative instrument in the field of alcohol and drug abuse. The ASI may be administered by a technician in 20 to 30 minutes producing 10-point problem severity ratings in each of six areas commonly affected by addiction. Analyses of these problem severity ratings on 524 male veteran alcoholics and drug addicts showed them to be highly reliable and valid. Correlational analyses using the severity ratings indicated considerable independence between the problem areas, suggesting that the treatment problems of patients are not necessarily related to the severity of their chemical abuse. Cluster analyses using these ratings revealed the presence of six subgroups having distinctly different patterns of treatment problems. The authors suggest the use of the ASI to match patients with treatments and to promote greater comparability of research findings.

                Author and article information

                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                17 March 2020
                March 2020
                17 March 2020
                : 3
                : 3
                [1 ]Birmingham VA Medical Center, Birmingham, Alabama
                [2 ]University of Alabama at Birmingham School of Medicine, Birmingham
                [3 ]University of Alabama at Birmingham School of Public Health, Birmingham
                [4 ]VA Greater Los Angeles Health Care System, Los Angeles, California
                [5 ]David Geffen School of Medicine at University of California, Los Angeles, Los Angeles
                [6 ]Pittsburgh VA Medical Center, Pittsburgh, Pennsylvania
                [7 ]University of Utah School of Medicine, Salt Lake City
                [8 ]Centers for Disease Control and Prevention, Atlanta, Georgia
                [9 ]VA Salt Lake City Health Care System, Salt Lake City, Utah
                Author notes
                Article Information
                Accepted for Publication:
                Open Access: CC-BY License JAMA Network Open
                Corresponding Author: Kevin R. Riggs, MD, MPH, Birmingham VA Medical Center, 1717 11th Ave S, Medical Towers 610, Birmingham, AL 35205 ( kriggs@ ).
                Author Contributions:
                Concept and design:
                Acquisition, analysis, or interpretation of data:
                Drafting of the manuscript:
                Critical revision of the manuscript for important intellectual content:
                Statistical analysis:
                Obtained funding:
                Administrative, technical, or material support:
                Conflict of Interest Disclosures:
                Role of the Funder/Sponsor:
                Copyright 2020 Riggs KR et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                Original Investigation
                Online Only
                Substance Use and Addiction


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