Homelessness and addiction: Surviving the opioid crisis

Fentanyl, oxycodone (OxyContin), hydrocodone (Vicodin), codeine, morphine. These synthetic painkillers, known as opioids, gained notoriety as extremely potent and highly addictive prescription drugs. Now, illicit versions of these drugs — including fake prescription pills laced with lethal amounts of fentanyl — are flooding communities across the state.

In Santa Cruz County, the opioid crisis is affecting our most vulnerable residents at alarming rates. Of the 42 people in Santa Cruz County who died last year as a result of opioid overdose, according to Santa Cruz County Coroner data, 26 were experiencing homelessness at the time.

Agencies are stepping up to help with expanded outreach and options for medically assisted treatment. But housing remains a top priority for helping people survive opioid addiction.

Opioids everywhere

Once thought to be more of an East Coast problem, fentanyl — an opioid 50 times stronger than heroin — is now prevalent across the U.S. Nationally, drug overdoses (most of which have been linked to fentanyl) are now the leading cause of death for Americans under the age of 50. To help spread the word and raise awareness about the deadly substance, the U.S. Senate has now designated May 9 as National Fentanyl Awareness Day.

Fentanyl is routinely found in trace amounts in street drugs such as methamphetamine, cocaine, MDMA, and heroin. But what is even more concerning is its routine presence in fake prescription pills sold for managing chronic conditions such as anxiety, fibromyalgia and insomnia. Just two milligrams of fentanyl — the equivalent of two grains of salt — is considered a lethal dose.

In 2022, California law enforcement seized 28,765 pounds of illicit fentanyl powder, an amount lethal enough to kill every person in North America. In April 2023, Alameda County law officials seized 92.5 pounds of fentanyl from illegal drug labs in Oakland and Hayward. 

Why do makers of street drugs add such a dangerous substance to just about anything? To amp up addiction, as well as product demand. A now-common story is that someone buys fake prescription pills on the street or through social media, thinking those pills are Xanax or Percocet, and that individual ends up overdosing from fentanyl poisoning.

In 2021, at least 7,125 Californians died as a result of opioid-related overdoses, according to the California Department of Public Health. That same year (the most recent year for which data is available), at least 21,016 Californians were rushed to hospital emergency rooms to receive life-saving treatment for drug overdoses.

Homelessness and drug use

While substance abuse and addiction affects people of all socioeconomic backgrounds, people experiencing homelessness are especially vulnerable to the deadly consequences of opioid use. 

“Fatal overdose is the leading cause of death among people experiencing homelessness in California,” said Joey Crottogini, Health Center Manager for Homeless Persons Health Project (HPHP), a Santa Cruz County-run clinic located on the Housing Matters campus. This population is particularly vulnerable, he said, because they are trying to manage symptoms of untreated disorders. 

“Addiction often starts with prescriptions for [medications like] Xanax, and other [medications] people try to get without a prescription,” he said. “Unless you have a really good medical team helping you taper down, you can become addicted really easily. We see it time and time again … in my experience, the motivating factor is not to get high, it’s to not feel sick.” 

That perspective aligns with data from the 2022 Point-in-Time Count, which shows that 49% of people experiencing homelessness report dealing with a chronic health issue, while 77% report dealing with a disabling health condition. Additionally, 67% of people experiencing homelessness in Santa Cruz County report struggling with addiction.

Source: Santa Cruz County 2022 Point-In-Time Count & Survey.

Of course, addiction and illicit drug use are extremely common, affecting people in every community regardless of where they live or how much money they earn. The California Health Care Foundation estimates that more than 2.9 million Californians struggle with a substance abuse disorder.

We probably all know someone who has problems with addiction … It’s just more visible for those who don’t have the resources to hide it.

— Chloe Bradburn, Service Navigation Coordinator at Housing Matters

Bradburn works daily with people experiencing homelessness to connect them to needed services, including substance abuse counseling, treatment centers and housing. 

“Traumatic experiences might lead folks to turn to street drugs as a coping mechanism,” she said. “While they might not be inclined to seek professional treatment for their health challenges … people experiencing homelessness may turn to neighbors in their community for support.”

Recovery requires housing

Unfortunately, addiction often sabotages a person’s ability to take care of basic needs, including finding and keeping employment, maintaining stable housing, and seeking treatment for long-standing health concerns. A cycle of taking drugs to cope — and then losing jobs, apartments and hard-won treatment progress — begins.

To help people break that cycle, Bradburn believes low-barrier access to housing and longer-term supportive services are necessary. 

“Housing provides some stabilization so people can address their addiction,” she said. “But there needs to be deeper layers of on-going support to sustain that housing.”

HPHP’s Crottogini agrees:

It’s very difficult to maintain any kind of treatment if you’re not housed. You’re in an environment where there’s lots of exposure to substance use, where people are using [substances] as a survival tool all around you, and at the same time you have competing priorities for food, clothing and shelter. I can’t overstate how difficult that is.

— Joey Crottogini, Health Center Manager for Homeless Persons Health Project (HPHP)

HPHP provides treatment on an outpatient basis for addiction as well as other untreated health conditions. The clinic offers medically-assisted withdrawal, free Narcan/naloxone distribution (an emergency opioid inhibitor that counteracts overdose), and free needle exchange as just some of their addiction-related services. But easier access to housing and additional treatment modalities are needed to help people move from survival to recovery.

“The public says that this is an individual problem, but we know it’s not that simple,” noted Crottogini. “Even people with insurance have difficulty accessing [substance abuse] treatment because of their insurance provider.”

Overcoming barriers 

Barriers to treatment are extensive, including:

  • Long waitlists for in-patient treatment center services (especially for those that accept MediCal)
  • Logistical challenges such as not having a cell phone with which to make or receive calls 
  • Not having transportation to get to appointments 
  • Not having the ID or documentation needed to access treatment

Even something as simple as not having a safe place to store medications like methadone and buprenorphine — two medications typically prescribed for managing opioid addiction — can become a barrier to treatment for people experiencing homelessness. 

Mental illness itself is also a barrier.

“The co-occurrence of mental health issues and substance abuse is very common,” said Karen Kern, Deputy Director of the Behavioral Health Division for Santa Cruz County’s Health Services Agency. “If recovery were as simple as getting into housing or getting into treatment, people would do it. But it’s a lot more complex than that.”

Kern — who oversees the County’s behavioral health services continuum of care — would know. She spent 10 years living unhoused as she struggled with an opioid and stimulants addiction. 

“My inability to stop using substances led to other things, like losing my job, my car, my apartment,” she said. 

Kern was in jail when she discovered she was pregnant. That discovery led her to seek treatment for her addiction, which involved a five-month wait for a bed in a residential treatment program. She was homeless once more following treatment, because she couldn’t immediately find affordable housing. Then, after moving into a studio apartment for herself and her infant son, she was able to begin the years of recovery that led her to where she is today.

There’s so much stigma attached to being homeless, and to substance use. You’re not seen as someone providing value.

— Karen Kern, Deputy Director of the Behavioral Health Division for Santa Cruz County’s Health Services Agency

She believes that for people to have a chance at long-term recovery from drug addiction and homelessness, they need low-barrier access to housing as well as wraparound services that extend beyond just six months to a year. Kern sees permanent supportive housing — which co-locates housing with on-site services — as a promising model.

“This approach to housing without services … makes it easy for people to fail. And without housing it is next to impossible to access and engage in services,” she said. “You’re not going to flip a switch and become a different person overnight. Recovery takes time.”

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Claudia Graziano Burgin is a Santa Cruz-based freelance writer who specializes in writing about community issues, and issues related to health.