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Suicides and Opioid Related Deaths
The term “deaths of despair” (DoD) broadly refers to deaths from suicide, drug overdose, and alcohol abuse, a category of deaths that have been on rising precipitously (Case & Deaton, 2020). While this epidemic once seemed to be confined to White Americans, it is now obvious that this is not the case. In South Shore the epidemic is seen in opioid overdoses and suicide death trends, shown in Figures 1 and 2. Alcohol deaths are harder to track; however, they are likely occurring as approximately 18.9% of residents in South Shore report binge drinking (Nichols et al., 2019). In all, 245 people in South Shore have had recorded deaths from suicide and/or opioids between January 2014 and January 2023 (Cook County Medical Examiner, 2023).
Deaths from opioids and suicides by race in South Shore are congruent with the demographics of South Shore, a community of about 54,000 residents, of whom 92.7% are black/African American (Chicago Metropolitan Agency for Planning, 2022James). However, in Chicago, opioid deaths are disproportionately concentrated among black residents (Jordan, 2018). Deaths of despair have been characterized as occurring in white America, leaving little attention being paid to the deaths of people of color (James & Jordan, 2018). Programs to address DoD should be community centered with knowledgeable providers and those with lived experience at the forefront to combat racially discriminatory practices and information. The ways in which opioids kill likely differ between racial groups (ex: cocaine vs heroin) which means different paths to well-being may be needed (James & Jordan, 2018). Additionally, black opioid users have less access to an already sub-optimal substance abuse treatment system and are disproportionately arrested and convicted of drug crimes compared to white opioid users due to incentive systems within the criminal justice system created by the War on Drugs (Alexander, 2012; James & Jordan, 2018). Therefore, programs must focus on building trust and avoiding punitive measures.
Despair is a heterogenous phenomenon that can arise as an emotional, biological, behavioral, or cognitive response to a situation at an individual or community level (Shanahan et al., 2019). The Centers for Disease Control and Prevention lists several community/society level risk factors for suicide that are relevant to South Shore, including “lack of access to healthcare,” “community violence,” “historical trauma,” “discrimination,” “stigma associated with help-seeking and mental illness,” and “easy access to lethal means of suicide among people at risk” (Centers for Disease Control and Prevention, 2022). Community level risk factors for opioid overdose are less readily available, however it is known that suicides and drug overdoses share risk factors (Colpe, 2022; Webster, 2017). Reducing DoD will require addressing the root causes of these factors, such as housing instability, financial instability, and health access/knowledge.
Unstable housing is an important modifiable risk factor for South Shore. As of 2022, 16.2% of households in South Shore spend more than 30% of their income on housing (Chicago Metropolitan Agency for Planning, 2022). Housing is also related to DoD in multiple ways. A study of people entering substance abuse treatment on the west side of Chicago found that people living alone had an increased risk of mortality, a finding that is highly relevant to South Shore where half of households are single people (Chicago Metropolitan Agency for Planning, 2022; Scott et al., 2011). Other studies have found that higher eviction rates lead to higher rates of overdose in urban counties (Bradford & Bradford, 2020; Venkataramani & Tsai, 2020). South Shore has the second highest eviction rate in Chicago (The Eviction Lab at Princeton University & Cook County Sheriff’s Office of Research, 2018) Housing instability is also related to lower access to healthcare and higher psychological distress, which are risk factors for DoD (Bradford & Bradford, 2020).
Financial instability is familiar stressor to many people. The median income per capita in South Shore is 70% of Chicago’s (Chicago Metropolitan Agency for Planning, 2022). Mental health deterioration is often linked to increasing economic insecurity, such as was experienced by many because of COVID-19 (Beseran et al., 2022) Finances can contribute not only to housing instability and mental stress, they can also be a barrier to private medical care. As of 2019, there was only one publicly funded behavioral health service provider in South Shore (Healthy Chicago, 2019). Mental health is an important intermediate factor of DoD (Beseran et al., 2022). Often one will meet the criteria for a “diagnosis of despair,” which are also on the rise, before a DoD (Brignone et al, 2020). Access to mental health treatment is important in the social ecological model of DoD. Similarly, higher access to regular medical care is related to lower levels of DoD at a county level (Zeglin, Niemela & Baynard, 2019). Increasing financial stability and providing knowledge about navigating complex treatment systems may increase access.
Deaths of despair are often the direct consequence of fentanyl, which is increasingly available in Chicago and found as a contaminant in many products (DEA Chicago Field Division, 2019). Interpersonal relationships that determine where and from whom one obtains opiates can determine whether one is exposed to fentanyl and whether they are aware of potential contamination; however, illicit drug distributors are often unaware of fentanyl contamination (DEA Chicago Field Division, 2019; Hassan, 2022). Interpersonal relationships also determine if one has knowledge of how to manage dosing and whether one has anyone available to deliver care in case of an overdose (Hassan, 2022). Interpersonal relationships with peers may also determine how much fear of stigma and social judgment one feels, which have been found to be significant barriers to seeking and continuing treatment among black mental health consumers (James & Jordan, 2018). Positive relationships within a community, which may protect against deteriorating mental health and provide important knowledge/support, are an important protective link that is often broken in the face of adversity (Shanahan et al., 2019). Programs can focus on building such relationships in order to have long lasting and wide-reaching impacts.
Project Overview
The goal of this program is ultimately to decrease the number of deaths of despair (DoD) in South Shore, to be accomplished by providing supportive housing to people at high risk. Additional objectives of the program include improving participant quality of life scores, housing stability, financial stability, and harm reduction knowledge, as measured by a modified WHOQOL survey, with added questions about housing stability and health knowledge/ empowerment over the course of one year (World Health Organization, 2012).
The first program input is the wealth of knowledge that exists in the Housing First and Liberatory Harm Reduction movements, which will be incorporated into staff training (Hassan, 2022; Polvere et al., 2014). Many housing programs require recipients participate in treatment and/or remain sober. However, this is unnecessary to see improvement and can delay housing and decrease participant empowerment (Hassan, 2012; Tsemberis, Gulcur & Nakae, 2004). Traditionally, housing first models focus on people who are already homeless. However, the process of becoming homeless is traumatic. Additionally, most people experiencing homelessness in Chicago report previous precarious housing situations, indicating they could be identified before homelessness occurs (Nathalie P. Voorhees Center for Neighborhood & Community Improvement, 2019).
This program will therefore target people who have gone through recent inpatient and/or outpatient treatment for a diagnosis of despair (depression, substance abuse, etc.) who have indicated they will have no housing or unstable housing after leaving the treatment facility. While only targeting people who have contact with the medical system will introduce inequity, for this pilot program, the benefits of easier identification and follow up make this necessary. Future programs should eliminate this requirement. Leaving inpatient care is a precarious time when one is at heightened risk for becoming homeless; however, very few people receive specialized treatment for substance use disorders (National Association of Addiction Treatment Providers, n.d.). By targeting both inpatients and outpatients this program hopes to capture many people and to capture people who have only irregular contact with the medical system (i.e. emergency room). Participants will need to be 18 years of age or older and be capable of signing legal documents, such as leases, themselves. Figure 3, see next page, outlines the logic model of this program, which is discussed further below.
This program will offer either case management/peer support with housing or case management/peer support only if housing funding is at capacity or if a suitable housing situation cannot be arranged within the confines of the program. If more potential clients are identified than can be served, clients will be enrolled on a first come first serve basis and a waiting list will be created. This pilot project would aim to provide housing assistance to roughly 25-30 people over the trial period and to provide case management/peer support to another 40-50 people. Housing assistance would come in the form of partial rental payments. Rental payments would primarily be made for new apartments; however, if a client was already renting a suitable apartment but struggling to keep the apartment, rental payments could be made for existing apartments. Clients would be provided access to case management services, and peer support directly through the program. Additionally, case managers would coordinate with community service organizations to secure other needed services for clients. Case managers and peer support staff would assist clients with navigating welfare applications and inform clients of resources. Peer support staff would meet with clients to work through their goals, provide emotional support, and teach harm reduction strategies.
Timeline
After funding has been secured, the first steps, shown in Figure 4, will be to hire/train case managers and peer support staff. Case managers will be licensed social workers. Peer support staff would be people with lived experience with substance abuse and/or depression, ideally from South Shore. Team members will be trained in housing first models, liberatory harm reduction principles and oriented to resources in South Shore. Next, team members will identify housing in the area, form connections with local housing providers and create housing protocols that are acceptable to landlords and potential clients (Polvere et al., 2014). Team members will identify health service providers that serve South Shore residents and form connections to expediate service provision for clients and identify resources for vulnerable populations. Behavioral health service providers with the capacity to identify and assist in enrollment of clients will be engaged to create enrollment procedures specific to their organization.
Once housing and enrollment procedures are in place, the team will begin to onboard clients. Ideally, clients would meet with their case manager and a peer supporter before leaving in patient treatment programs and within a few days of receiving outpatient treatment. During this meeting program staff will ascertain what services the client needs and what housing would be suitable to them. Then, staff will identify if the program can meet these needs and coordinate.
This program will address determinants on the local community level by increasing the affordability of housing, addressing other barriers to housing and increasing the number of jobs for people with lived experience of mental illness and/or substance abuse. This program will address determinants on the interpersonal level by increasing health knowledge and increasing participants’ sense of belonging via relationships with peer support staff. Finally, this program will address determinants at the larger community level by managing resources so that money is funneled into South Shore via rent payments/employment and making sure decisions about how that money is allocated is made by stake holders (i.e., client’s choice of housing).
This program aligns with Ascension’s mission of focusing on vulnerable/impoverished populations and promoting wholistic, dignity focused care (Ascension, n.d. B). Ascension will hire staff for this program, organize funding sources, and oversee the administrative tasks required for these activities. Additionally, some clients may be identified and enrolled through health facilities owned by Ascension. Ascension is well suited to run this program. This program would require substantial funds to operate and would require experienced grant writers/fund raisers in order to obtain continued funding. Ascension is a large organization with many resources (financial, staff, expertise, etc). It operates a similar housing program in South Shore (The Bettendorf Place) and has experience using multiple funding sources to fund housing programs (CHANGE Chicago Housing Authority, 2010). Additionally, Ascension has experience creating connections to services for housing clients (Ascension, n.d. A).
This program will require collaboration with many partner organizations. Partner organizations will initially be used to help identify and enroll clients. Partner organizations will also provide additional services and that patients are linked to. Examples of potential partner organization include Jackson Pk Hospital & Medical Center, South Shore Hospital, Ratcliff Behavioral Medicine & Research, UI Health, etc.