From the Editor

With the shelter system overcrowded, my patient slept the previous four nights in the train station. “Where else was I to go?” Many major cities across North America have seen a rise in the number of those who are chronically homeless. Housing First – the idea that stable housing is needed for people to better access health care – is one option, though the concept has been increasingly criticized. Is it a good fit for our urban problems?

In the first selection from Health Affairs, Devlin Hanson and Sarah Gillespie (both of the Urban Institute) consider Housing First for a specific population: the chronically homeless population who have had frequent arrests and jail stays; most of them, not surprisingly, have major mental illness or substance problems. Hanson and Gillespie analyzed data from Denver, Colorado, where people were randomized into Housing First or a control group. “We found that within the two-year study period, people in the intervention group had significantly more office-based care for psychiatric diagnoses, fewer ED visits, more unique medications, and greater use of other health care than people in the control group.” We review the study and its implications.

Denver: mountains, fresh air, and Housing First

In the second selection, Hai V. Nguyen (of Memorial University) and his co-authors look at safe supply and opioid outcomes in British Columbia. In a JAMA Internal Medicine paper, they used data from that province, contrasting it with Manitoba and Saskatchewan, and focused on the number of prescriptions and hospitalizations. “Two years after its launch, the Safer Opioid Supply Policy in British Columbia was associated with higher rates of prescribing of opioids but also with a significant increase in opioid-related hospitalizations.”

Delirium is common in the elderly admitted to hospital, and antipsychotics are often prescribed. In the third selection, Dr. Christina Reppas-Rindlisbacher (of the University of Toronto) and her co-authors comment on use of this medication in aCMAJ Practice paper. They offer much advice, including: “They should be prescribed at the lowest effective dose for the shortest possible duration and be reevaluated at or shortly after discharge.”


Selection 1: “‘Housing First’ Increased Psychiatric Care Office Visits And Prescriptions While Reducing Emergency Visits”

Devlin Hanson and Sarah Gillespie

Health Affairs, 24 January 2024

Housing First is an approach to ending homelessness that recognizes housing as a platform for stability and engagement in health services. In contrast to approaches that require people to receive treatment for mental health or substance use disorders before securing housing, Housing First is built on the idea that people must have safe, affordable, and permanent housing to consistently engage with other services such as needed health care. The Housing First approach is often used in permanent supportive housing programs, which combine long-term rental assistance and supportive services designed to maintain housing stability for people experiencing chronic homelessness. Evidence has been mounting on the effectiveness of permanent supportive housing for outcomes such as housing retention and reductions in jail time, but rigorous evidence of its impact on health care use has been mixed…

Studies on the impact of supportive housing on hospitalization rates, lengths-of-stay, use of the emergency department (ED), psychiatric hospitalizations, detoxification facility days, and residential alcohol and drug treatment days have had mixed results…

In 2016, the City and County of Denver, Colorado, launched the Denver Supportive Housing Social Impact Bond Initiative (SIB), a supportive housing intervention designed to serve a chronically homeless population that had frequent arrests and jail stays.

So begins a paper by Hanson and Gillespie.

Here’s what they did:

  • Those who were chronically homeless were randomized into a Housing First group and a control group.
  • They drew from different sources of data, including the Denver Police Department and Medicaid (if people were enrolled in a managed care program).
  • In terms of housing: “People in the intervention group who received housing were housed in either a scattered-site unit rented with a housing subsidy in the private rental market or a single-site building fully dedicated to supportive housing units.”
  • “We analyzed the intervention’s impact on health care use, Medicaid enrollment, and mortality among people experiencing chronic homelessness who had frequent arrests and jail stays.”

Here’s what they found:

  • A total of 724 people were randomly assigned to either the intervention group (363) or the control group (361) on a rolling basis.
  • Diagnoses. “Medicaid claims showed high rates of mental health diagnoses (37%) and substance use disorder (SUD) diagnoses (67%), as well as injuries and poisonings (36%) among people in the study sample…”
  • Psychiatric care. “Participants had an average of eight more office-based visits for psychiatric diagnoses, three more prescription medications, and six fewer emergency department visits than the control group.” (Those participants who were actually housed had even more office visits: on average, ten.)
  • Medicaid enrollment. “Although enrollment in Medicaid increased over the course of the study for both the intervention group and the control group, the intervention group was 5 percentage points less likely to be enrolled in Medicaid.”
  • Mortality. Supportive housing had no significant impact on mortality. (!)

A few thoughts:

1. This is a good study with a nice dataset.

2. The major finding in a sentence: Housing First resulted in more health care use (including office-based visits) but fewer ED visits.

3. The authors note the significance: “Unlike services as usual, the Housing First intervention led to a shift from ED visits to community-based care, which potentially enabled participants to address physical and mental health concerns in a timely manner and avoid health crises.”

4. It wasn’t just about the housing, of course. The Housing First program included ACT services.

5. Like all studies, there are limitations. A major one: health-care utilization was based on Medicaid claims but not all participants were enrolled in this public program.

6. On a related note and with a Canadian context, Dr. Sandy Simpson (of the University of Toronto) and his co-authors wrote about stopping the “growing triad of mental illness, incarceration and homelessness” in a Globe and Mail essay. The list of solutions includes Housing First. You can find that article here:

The full Health Affairs paper can be found here:

Selection 2: “British Columbia’s Safer Opioid Supply Policy and Opioid Outcomes”

Hai V. Nguyen, Shweta Mital, Shawn Bugden, et al.

JAMA Internal Medicine, 16 January 2024

Canada’s opioid crisis has accelerated markedly in recent years. In 2022, 14 opioid-related poisoning hospitalizations occurred each day, while 20 people per day died of an overdose on average. With potent synthetic opioids from the unregulated market fueling this crisis, there is growing interest in offering a safe supply of regulated, pharmaceutical-grade opioids to people who use drugs to help reduce the risk of overdose and poisonings.

In March 2020, British Columbia became the first jurisdiction globally to launch a provincewide Safer Opioid Supply policy that allows individuals at high risk of overdose to receive pharmaceutical-grade opioids free of charge prescribed by a physician or nurse practitioner. This policy initially covered select opioids (hydromorphone and sustained-release oral morphine), and in July 2021, it was made permanent and expanded to include additional drugs, including injectable fentanyl. In June 2023, 4619 people were prescribed safer supply opioid medications…

While this harm-reduction policy is intended to reduce overdose or poisoning risks and remove barriers to care access for people who use drugs, some people suggest that the limited range of lower-potency opioids available through safer supply programs may not meet the needs of people who use drugs and are accustomed to high-potency opioids. Furthermore, there are concerns that providing a safer supply could discourage people who use drugs from receiving proven substance use treatment and encourage potential diversion of prescribed opioids…

So begins a paper by Nguyen et al.

Here’s what they did:

  • “This cohort study used quarterly province-level data from quarter 1 of 2016 (January 1, 2016) to quarter 1 of 2022 (March 31, 2022), from British Columbia, where the Safer Opioid Supply policy was implemented, and Manitoba and Saskatchewan, where the policy was not implemented (comparison provinces).”
  • The main outcomes: “rates of prescriptions, claimants, and prescribers of opioids targeted by the Safer Opioid Supply policy (hydromorphone, morphine, oxycodone, and fentanyl); opioid-related poisoning hospitalizations; and deaths from apparent opioid toxicity.”

Here’s what they found:

  • Descriptive statistics. After policy implementation, number of opioid prescriptions dispensed: this “increased sharply” in BC; number of people with at least 1 opioid prescription dispensed (referred to as opioid claimants): a slight increase in BC; the number of opioid prescribers: no major changes; hospitalizations: up in BC. See figures below.
  • Regression analyses. After policy implementation, the number of opioid prescriptions: “statistically significant increases” in rates of prescriptions (2619.6 per 100 000 population…) and the number of claimants (176.4 per 100 000 population…); the number of prescribers: “no significant change” (15.7 per 100 000 population); hospitalizations: increased by 3.2 per 100 000 population.  

A few thoughts:

1. This is a good study – with clear data on an important topic, published in an excellent journal.

2. The main findings: prescriptions were up in BC, but not claimants or prescribers (no surprise); that said, opioid hospitalizations were up (ouch).

3. Perspective: “There were no statistically significant changes in deaths from apparent opioid toxicity…”

4. Like all studies, there are limitations. The authors note several, including that comparisons were made with just two (smaller) provinces, Manitoba and Saskatchewan.

5. The authors describe the rise of hospitalizations as “potentially concerning.” How to explain it? “One potential reason is that participants in British Columbia’s Safer Opioid Supply policy program diverted safer opioid supply for various reasons, including to purchase unregulated fentanyl. It is also possible that a higher supply of prescription opioids led to an increase in prescription opioid misuse, which in turn, could increase hospitalization risks. Another possibility is that availability and/or toxicity of an unregulated drug supply increased more in British Columbia than in comparison provinces, leading to more hospitalizations in British Columbia.”

The full JAMA Int Med paper can be found here:

Selection 3: “Antipsychotic medications for older adults with delirium admitted to hospital”

Christina Reppas-Rindlisbacher, Lesley Wiesenfeld, Nathan M. Stall

CMAJ, 14 August 2023

Delirium occurs in 30%–50% of adults aged 65 years or older admitted to hospital, and may be hypoactive (lethargy, reduced psychomotor functioning), hyperactive (agitation, hallucinations) or mixed. Twenty-nine percent of patients with delirium admitted to hospital in the United States are newly started on antipsychotic medications.

So begins a practice article by Reppas-Rindlisbacher et al.

They make several points, three of which are summarized here.

Antipsychotic medications should not be used as standard treatment for delirium

“Delirium management includes addressing underlying causes, optimizing environmental factors and implementing nonpharmacologic interventions. A 2019 systematic review reported no difference between antipsychotic medications and placebo on delirium duration or severity, length of hospital stay or mortality.”

Antipsychotic medications may be considered for patients with delirium experiencing severe agitation or distress

“Antipsychotic medications may be used for patients with delirium who are at risk of self-harm, harming others or compromising essential medical therapy, or for patients with psychotic symptoms experiencing substantial distress. They are preferred over benzodiazepines, except for specific indications such as delirium associated with alcohol or benzodiazepine withdrawal.”

Assessment of individual risks and benefits is warranted prior to use given serious adverse effects

“The adverse effects of antipsychotic medications include sedation, hypotension, falls, parkinsonism, QT interval prolongation and aspiration pneumonia. Antipsychotic selection should consider adverse effects, desired outcome, relative contraindications and preferred administration routes…”

A couple of thoughts:

1. This is a clear and practical summary of the topic.

2. To steal a line from Dr. Richard Goldbloom: today’s dogma is tomorrow’s malpractice. Not that long ago, antipsychotics were the standard treatment.

The full CMAJ paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.