California passed the Community Assistance, Recovery, and Empowerment (CARE) Act in 2022 to provide behavioral health and housing services to individuals with psychotic spectrum and schizophrenia disorders who are deemed unable to care for themselves. This policy brief from the Benioff Homelessness and Housing Initiative at UCSF and the California Policy Lab uses anonymized data to estimate how many San Franciscans in a database of individuals who have contact with the urgent and emergent care system may be eligible for referral to CARE Court and describe their service needs.

People experiencing homelessness (PEH) have a high rate of tobacco use. Researchers examined factors associated with cigarette consumption and quit attempts. They found having an encounter with staff in the past week was associated with a 40% reduction in weekly consumption. The findings highlight the role of community-based pharmacists to expand smoking cessation services in homeless shelters.

Over 60% of permanent supportive housing (PSH) residents smoke cigarettes, and over 50% use cannabis. Co-use of tobacco and cannabis may be linked with other substance use. We explored attitudes toward tobacco-free and cannabis-free policies among PSH residents who smoked cigarettes, co-used tobacco and cannabis, or other substances.

The homeless population is aging and adults who experience homelessness for the first time in older age are more likely to progress to chronic homelessness. To prevent or delay homelessness, many people live temporarily live with family or friends. In this qualitative study of homeless older adults, researchers conducted 46 semi-structured interviews. They found that structural barriers to family and friends providing housing for temporary or permanent exits from homelessness included housing regulations, geographic and transportation challenges, and environments inconducive to older adults.

Behavioral health challenges both contribute to and are exacerbated by homelessness. To better understand behavioral health and homelessness, we examined data from the California Statewide Study of People Experiencing Homelessness. Our latest report examines the relationship between homelessness, substance use, and mental health, providing critical insights for policymakers, program leaders, Continuum of Care leaders, and healthcare systems.

In this op-ed, BHHI Professor Meghan Morris, discusses how improved testing can address racial disparities, and how device companies can play a vital role in eliminating this public health threat.

Researchers examined whether childhood adversity is associated with depressive symptoms, suicide attempts, or psychiatric hospitalization among older homeless adults. Using population-based sampling methods, the study enrolled 350 homeless adults aged 50 and older in Oakland, California. They found that childhood adversities are associated with poor mental health outcomes among older homeless adults. Researchers recommend screening for childhood adversities should be undertaken by all providers who care for older homeless adults.

This study from BHHI researchers describes five distinct subgroups of the highest users of the health care system in San Francisco with differential comorbidities, health care needs, and social determinants of health, spanning from patients with medical comorbidities solely using medical services to patients grappling with housing insecurity, incarceration, substance use disorder, and mental health comorbidities. Frequent users of the health care system are not a homogenous population as previously thought. This study sheds new light on how to help the most vulnerable patients and inform clinicians and care coordination teams on making sure patients get the care they need the most. 

In the United States there has been a simultaneous rise of mass incarceration and homelessness. Both of these phenomena are driven by the same structural factors, housing being the most important. Researchers present evidence-based approaches to improve housing strategies for reentry populations, prevent homelessness among those in community supervision, and rehouse members of the reentry community experiencing homelessness.

In this op-ed, Ryan Assaf, PhD, MPH, a postdoctoral fellow with the Benioff Homelessness and Housing Initiative, highlights the importance of using harm reduction strategies. He outlines the use and impact of needle exchange programs, reducing the transmission of viral infections and acting as a bridge to other services. Dr. Assaf further emphasizes that criminalizing drug use will not make the problem disappear. "These services create a space of trust where individuals who use drugs can seek help, referrals, and navigation to substance use treatment and counseling if and when they are ready for it." Dr. Assaf writes. This op-ed was published as part of the Public Voices Fellowship in partnership with The OpEd Project and funding from the California Health Care Foundation.

In this op-ed, Maya Vijayaraghavan, MD, MAS, director of the UCSF Smoking Cessation Leadership Center, highlights the need for widespread access to tobacco treatment among people experiencing homelessness and the structural issues underpinning tobacco use. She emphasizes that in the homelessness advocacy and provider community should not normalize tobacco use among people experiencing homelessness and there is increased awareness and trained staff in shelters to provide tobacco treatment. "Providing tobacco treatment will substantially reduce harm, save lives, and improve financial stability by supporting quitting." Dr. Vijayaraghavan writes. This op-ed was published as part of the Public Voices Fellowship in partnership with The OpEd Project and funding from the California Health Care Foundation.

The United States is taking a sharp turn in how it addresses homelessness after a new executive order calling for more "involuntary commitment," which is a process in which mental health workers can forcibly detain and medicate people against their will. Studies have shown that the housing first model is significantly cheaper and more effective than involuntary detention. "Americans want there to be no homelessness. And this is...a formula to worsen homelessness," says BHHI Director Dr. Margot Kushel of efforts to expand involuntary detentions & withdraw funding from communities that don't comply.

BHHI faculty member Maya Vijayaraghavan, MD, MAS, is a contributing author of this 2024 Surgeon General’s report on disparities in tobacco use and secondhand smoke exposure. The report ...

The prevalence of substance use decreases as individuals age, but older adults now have a higher prevalence of substance use than older adults did 10 years ago. People experiencing homelessness have a higher prevalence of substance use disorders compared to the general population. In this cohort study, researchers examined the prevalence of and factors associated with substance use in a population of homeless individuals aged 50 and older. They found a high prevalence of substance use and an association between psychiatric hospitalization and depression with substance use. Researchers also recommend targeted treatment programs and geriatric substance use workforce development.

About 70-80% of adults experiencing homelessness smoke cigarettes. Researchers examined guest support for on-property smoke-free policies within an homeless shelter amongst never smokers, former smokers, and current smokers. They found that 64% of participants supported a partial smoking ban, while 32% supported a full smoking ban. These findings illustrate that implementing smoke-free living/workplace policies in homeless shelters enjoys more support from guests.

In this cross-sectional study, researchers studied the association between residential relocation and health outcomes in people who inject drugs (PWID). PWID are at an increased risk of low socioeconomic status and homelessness. Researchers found that any residential movement in the past 30 days was associated with increased odds of bad health outcomes.

A groundbreaking UCSF BHHI study challenges common perceptions about drug use among people experiencing homelessness. Researchers found that less than half of this population regularly used drugs, with methamphetamine being the most common substance, not opioids. Many respondents wanted treatment but struggled to access it, highlighting barriers to care. The study emphasizes that homelessness and substance use are interconnected and advocates for reducing barriers to treatment and prioritizing housing solutions. "We need to reduce barriers to substance use treatment, and that includes prioritizing people’s ability to return to housing,” said BHHI faculty member Ryan Assaf, PhD, MPH, the study’s lead author.

Most people experiencing homelessness in California are not regular drug users — and for some, substance use begins or worsens after losing housing. Some use drugs to stay awake and safe, coping with the trauma and danger of life without shelter. At the same time, many who want treatment can’t get it. This paper uses data from the California Statewide Study of People Experiencing Homelessness to show a comprehensive, representative look at substance use, overdose risk, and unmet treatment needs among people experiencing homelessness in California.

People living with HIV/AIDS (PLWHA) have an increased risk of experiencing homelessness. The underlying drivers of homelessness are structural, however individual factors such as mental health and substance use problems are also common drivers. People living with HIV/AIDS who experience homelessness are more likely to have uncontrolled viral load. Researchers from BHHI suggest integrating HIV treatment with mental health and substance use treatment.

Populations experiencing homelessness have high rates of tobacco use and experience substantial barriers to cessation. Tobacco-caused conditions are among the leading causes of morbidit...

Alcohol use disorders (AUDs) are common among those experiencing homelessness. Managed alcohol programs (MAPs) are an evidence-based solution for helping people with AUD experiencing homelessness. Researchers examined and evaluated MAPs in Canada and California. They found that MAPs have successes and stabilization effects.

The U.S. overdose crisis is now driven by polysubstance use involving fentanyl and stimulants. We received funding through the National Institutes on Drug Abuse’s Helping to End Addiction Long-Term (HEAL) initiative to conduct longitudinal qualitative research on polysubstance use among people experiencing homelessness (PEH) in San Francisco, California. This paper discusses the rationale for these combined approaches and lessons learned from conducting longitudinal qualitative research with a community in real-time during enhanced risk for criminalization and overdose fatality.

A record number of seniors are burdened by high housing costs. A new report from University's Joint Center for Housing Studies sounds the alarm as the US population ages rapidly. The number of seniors who will qualify for federal housing subsidies will continue to grow. The report also notes that more people over the age of 50 are losing housing for the first time. Margot Kushel, MD, director of the UCSF Benioff Homelessness and Housing Initiative, said, "Increasingly, the story of homelessness among adults is going to be older adults living in poverty, who are spending what should be their retirement years in the streets."

This UCSF study examined deaths among people experiencing homelessness in San Francisco from 2016 to 2018. Although heart disease and cancer are the first and second causes of death for California’s general population, the leading causes of homeless deaths were acute intoxication (unintended overdose) and trauma (including homicide and suicide rates over triple that of the US general population). The authors advocate that these differences in cause-specific mortality should inform death prevention efforts within the homeless population differently than the general population.

This study from UCSF BHHI researchers examined deaths among people experiencing homelessness in San Francisco during the first year of the COVID-19 pandemic. They found 82% of 331 deaths were associated with drug overdose, not COVID-19 infection. Traumatic injury, including homicide and suicide, was the second most common cause of death. This research highlights a need for strategies that address both homelessness and drug use, including housing, evidence-based treatment of opioid addiction, and overdose prevention programs.