Joseph Silcox

Background and Aims: People experiencing homelessness (PEH) are disproportionately affected by chronic disease, serious mental illness, substance misuse and use disorders, and premature death compared to housed individuals. One housing approach for PEH living with substance use disorders is “low-threshold transitional housing” (LTTH)—a “Housing First” approach that includes the provision of harm reduction services and policies at housing sites. Few previous studies have investigated how LTTH shapes the substance use and health experiences of residents of LTTH over time. In Boston, Massachusetts, United States (US), 146 PEH were rapidly moved from a concentrated tent encampment area into LTTH between December 2021 to January 2022, with most sites remaining open through present. This qualitative study’s aim was to develop typologies that represent the varied drug use, health, and service use experiences of Boston LTTH residents. Methods: Prospective cohort study including semi-structured interviews conducted at baseline, 3-months, and 6-months between September 2023 and September 2024 with 28 participants living in six LTTH sites across Boston, Massachusetts, United States (US). We grouped experiences from the longitudinal interviews into typologies using an ideal-type analysis. To do so, we first conducted systematic comparisons over time between and within participants to form case reconstructions, which were ultimately grouped into “ideal-types” of similar cases. Optimal cases were selected to illustrate and conceptualize each ideal-type. To reach consensus around the typologies and enhance credibility, the research team engaged in group discussions. A reflexive approach was also incorporated to increase the dependability of the findings. Bivariate tests compared socio-demographics and substance use behaviors across typologies. Findings: Three typologies and one sub-typology were identified: Stabilization Throughout (Typology 1), Delayed Stabilization (Typology 1A), Inconsistent Stabilization (Typology 2), and Temporary Stabilization (Typology 3). While the pattern of change differed by typology, most residents experienced some degree of stabilization over time while living at LTTH via the initiation or continuance of medical and harm reduction service connection, exhibiting reductions in substance use, engagement in safer use behaviors, and increases in social connectedness. Typologies comprised of participants who were less stable via LTTH appeared to experience disruptive transitions and/or live with multiple chronic health conditions. Conclusion: Distinct typologies emerged describing the health and substance use experiences over time of people living in low-threshold transitional housing. The process of stabilization among low-threshold transitional housing residents not only differed by typology, but also demonstrated that the uptake of co-located medical, harm reduction, and social services within a low-threshold, trauma-informed environment coincided with improved health and formation or rekindling of social connections.

The overdose crisis in the U.S is complex, with opioid overdoses compounded more recently with rising stimulant-involvement. Individuals who experience or witness overdoses often avoid calling 911 due to fear of criminal-legal system consequences. Many U.S. states have "Good Samaritan Laws" (GSLs) protecting those seeking help for overdoses, but research is lacking on the understanding and role of GSL in overdose response among people who use stimulants (PWUS) and criminal-legal populations. Our mixed-methods analysis focused on PWUS from a community-based sample in a state with GSL protections, Rhode Island, and participants incarcerated at the Rhode Island Department of Corrections (RIDOC) for charges related to drug distribution. We analyzed survey and interview data to discern differences in knowledge and attitudes regarding Rhode Island's GSL in the two samples. Overall awareness of the GSL was widespread among the community sample (61.1%) and the RIDOC sample (63.3%); however, more RIDOC participants (70%) than PWUS in the community (42.9%) could accurately describe the law. Participants in both samples reported deeply rooted fears associated with the consequences of help-seeking and skepticism of protections provided by the GSL, particularly around criminal-legal consequences. While the Rhode Island GSL provides protections for probation or parole violations, many RIDOC participants were fearful that these protections would not apply to them, despite the law being amended to provide these protections. Additionally, participants from both samples reflected on differences in help-seeking behaviors among unexpected opioid and stimulant overdoses, discussing how their interpretation of overdose symptoms influenced decisions to call for help (e.g., call 911) or not. Varying degrees of understanding of the Rhode Island GSL, along with fears of police involvement in overdose situations, underscore the need for targeted interventions, policy change, and re-education efforts about overdose prevention and the GSL. Findings can inform policy and professional practices associated with GSLs.

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.

Illicitly manufactured fentanyl within the drug supply has substantially increased opioid-related overdose deaths and driven infectious disease outbreaks among people who use drugs (PWUD). Local jurisdictions often lack the data and tools necessary to detect and translate such moments into actionable and effective responses. Informed by a risk environment framework, this case study adopted a mixed-methods design spanning two rapid assessment studies with PWUD in Lowell (n = 90) and Lawrence (n = 40), Massachusetts, during an HIV outbreak (2017, Study 1) and following the outbreak (2019, Study 2). Survey responses (n = 130) were summarized by computing descriptive statistics, ethnographic field notes were reviewed, and qualitative interviews (n = 34) were thematically analyzed to contextualize quantitative findings. Study 1 participants reported constrained syringe access, high injecting frequency, syringe reuse, and unsafe syringe disposal practices, and uncovered entrenched social and structural factors exacerbating existing substance use and HIV risks: housing instability, limited harm reduction supplies and services (e.g., MOUD access), and tensions between law enforcement and PWUD. Following the outbreak and substantial local investments in harm reduction and treatment infrastructures, Study 2 participants indicated lower injection risk reporting fewer syringe reuse episodes, improved syringe disposal practices, high frequency of naloxone administration at recent overdoses, frequent testing for HIV and HCV, and greater engagement with syringe services programs. A rapid assessment approach to fentanyl’s emergence and a concomitant HIV outbreak provided time-sensitive, critical insights and identified needed and local response strategies. However, unless social and structural risk factors are also addressed, community vulnerability to future HIV outbreaks remains.