The New York City Association of
Homeless and Street-Involved Youth Organizations’

State of the City’s
Homeless Youth Report 2003

SUBSTANCE USE

Irene is a 20 year-old street homeless young woman whose time and labor is almost entirely devoted to staving off withdrawal symptoms. She began using heroin at fifteen when she fell in with a few older teenagers who, like herself, were staying on the streets for extended periods to avoid abusive and chaotic family lives.  Heroin offered Irene a sense of peace and internal organization, and she found it to be far more effective in managing symptoms of extreme anxiety and obsessive-compulsive disorder than the legal pharmaceuticals that doctors had prescribed her in the past.  Irene’s family was too dysfunctional to help her and other institutions such as school, the medical system and the child welfare system were shaped by “tough-love” approaches that encouraged withdrawal of services when Irene “failed” to access the only form of help deemed appropriate for drug using young people facing multiple problems--abstinence-based drug treatment prior to, or coupled with, any other services. Irene did not see drugs as her primary problem and was not willing give up her main coping strategy, but because she was young and a drug user, she was not consulted about her view of her own needs.

After various expulsions and arrests, Irene was offered an ultimatum that she found coercive and frightening--jail or an adult residential drug treatment program.  She picked the drug treatment option but immediately escaped to street homelessness in New York City, a world in which her interpersonal skills, resourcefulness, and capacity for nurturing others allows her to raise over 100 dollars per day through panhandling and occasional sex work to support her heroin habit, that of her boyfriend and to still buy enough dog food to keep their “baby” healthy and sleek.  Along the way she became infected with Hepatitis C, barely escaped death by overdose several times and was raped.  Had she been eligible for decent shelter, housing, or other supportive services as an active drug user, these outcomes could have been avoided.   

Irene began attending a Lower East Side homeless youth drop-in center for showers, syringe exchange, food and counseling.  Exhausted by the daily grind of raising money to stay well, she has chosen at times to reduce her drug use on her own with mixed results.  At other times she has mustered the energy to try to give up heroin entirely through substance abuse treatment.   As a homeless person without Medicaid, her options for detox and rehab are very limited, but she has successfully completed detox a few times only to be discharged to the street or referred to a rehab program several days travel away.   Realizing that she cannot successfully abstain from drugs without a stable place to stay, she has tried residential treatment in a “Therapeutic Community” setting inappropriate to her needs as a young person and was discharged after one relapse.  Continuing to struggle to implement her own harm reduction and reduced-use strategies until she again feels strong enough to contend with the drug treatment system, Irene says she can’t understand why those in a position to help her seem to want to make her life even harder. 

STATEMENT OF THE ISSUE

            The primary problem faced by drug using youth is the common understanding, informed by the medical model of addiction, that abstinence from drugs must be attained prior to the pursuit of any other goal, and that abstinence should be the primary goal for all users.  This belief has excluded young homeless drug users from every other form of help they could be eligible for, particularly from shelter and housing. 

             It is frequently noted that substance use can both cause a person to become homeless and keep him or her from being able to get off the streets.  However, lack of access to appropriate shelter, transitional living programs and permanent housing for drug using youth is not “caused” by their substance use, abuse or addiction, but by policies and program models that exclude serving active drug users.   There are few shelter or housing opportunities available to homeless youth who are not ready, willing or able to stop using drugs and no opportunities designed purposely for this population. 

             Whether young people intend to get assistance in abstaining from drug use, choose to try to manage their use so that lives are less chaotic or simply want to maintain their health, hygiene, nutrition, employment, education or relationships during periods of drug use, housing provides a level of stability necessary to the pursuit of any positive change.  Engagement in other services such as mental health or education is nearly impossible to sustain without some form of housing.  More than drug dependency itself, homelessness makes it close to impossible for drug users to manage their use and their lives.

EXISTING SERVICES/GAPS IN SERVICES

            Homeless drug using youth who want to sleep indoors will discover that some youth shelters require a medical clearance from a hospital documenting sobriety, if they suspect a resident is intoxicated.  Others are more tolerant of residents being somewhat intoxicated on occasion so long as they can behave appropriately but are understandably unable to accommodate the life patterns of people whose chemical dependency is not well managed if they are to maintain a level of structure and sense of consistency within a program.   Homeless youth who work nights doing sex work to maintain a habit for example, or who may have to buy and use drugs very late at night to avoid withdrawing during the wee hours cannot be accommodated by a shelter with a ten o’clock curfew designed to offer structure to other residents.  No youth shelter incorporates syringe exchange or any significant degree of harm reduction education services.  A few adult shelters are sufficiently disorganized and demoralized to tacitly tolerate drug use on the premises, but it is a rare young person who can tolerate these dangerous, depressing places.

            There are no transitional programs for homeless drug using youth and any person with a drug charge is ineligible for public housing and Section 8.  People who admit drug use in a routine Public Assistance application screening instrument are not eligible for benefits unless they agree to undergo abstinence-based treatment.

            Drug treatment (detox, rehab and long-term treatment) is less available each year to those without Medicaid or other insurance.  Opening a Medicaid case takes over a month and requires identification.  Obtaining identification is itself increasingly difficult for homeless people in New York City, particularly young people, as it requires the applicant to already have many forms of identification.

            Drug treatment models designed for adults, such as the therapeutic community model which emphasizes confrontation and adherence to communal norms and de-emphasizes individualized therapy are not appropriate to the developmental needs of adolescents who often struggle with identity and sexual identity issues and for whom an acceptance of the identity of “addict” may be a long way off.  These programs tend not to be sensitive to the needs of homeless youth who typically face the additional challenge of underlying and undiagnosed mental health issues which do not meet "MICA" criteria, and who usually have next to no social or familial support.  Where adolescents need to feel nurtured on one hand but also have their independence respected on the other, therapeutic communities tend to be harsh and unforgiving on one hand and paternalistic on the other.  There are few long term youth-focused drug treatment programs and those that do exist alter the therapeutic community model little if at all to reach adolescents.

RECOMMENDATIONS FOR SUBSTANCE USE SERVICES

·  Create program models for shelter, transitional living programs and permanent housing for youth who currently use drugs. 

·  Integrate harm reduction-based drug education, HIV/HCV (Hepatitis C Virus) and overdose education into schools and youth programs as well as homeless youth programs. 

·  Increase drug treatment beds for youth and offer youth specific models for long-term residential drug treatment incorporating a “stages of change” analysis of behavior change processes. 

·  Make homeless youth a special category with expedited access to Medicaid and identification. 

·  Incorporate syringe exchange into existing social programs and institutions and train staff in harm reduction philosophy.

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