International rapid evidence review of services for homeless people with substance misuse problems that considers models of service delivery and outcome measurement within a Scottish context.

A Rapid Evidence Assessment of international literature on effective substance misuse services for homeless people was conducted to review best practice in other countries and determine if there were any lessons for Scotland. The review found that:

* The relationship between substance misuse and homelessness appears quite complex. There is strong evidence of a mutually reinforcing relationship between these two social problems. An experience of homelessness increases the risk of substance misuse among previously abstinent people, while entering into substance misuse also increases the risk that someone will become homeless. There is evidence that when someone is homeless and involved in substance misuse each problem compounds the other ( Chapter 2).

* In Scotland, there is evidence that young homeless people, people with experience of sleeping rough and lone homeless people are characterised by higher rates of substance misuse than are found in the general population. There is evidence that parents and children in homeless families are either only a little more likely, or no more likely, to be involved in substance misuse than parents and children in the general population. The same pattern exists in England and in North America ( Chapter 2).

* There is a strong association between the presence of mental health problems or severe mental illness among homeless people with substance misuse problems in Scotland. The same pattern exists in England, the EU, North America and Japan ( Chapter 2).

* Services that are aimed solely at promoting abstinence among homeless people with a substance misuse problem tend to meet with quite limited success. There is evidence that many homeless people with a substance misuse problem either cease contact with these services before treatment or rehabilitation is complete or avoid such services to begin with. Attempts to use short stay detoxification services with homeless people have proven particularly unsuccessful ( Chapter 3).

* When services pursue harm reduction or harm minimisation policies, rather than insisting on total abstinence, there is evidence that they are able to engage with homeless people with a substance misuse problem more effectively. In particular, there is evidence that harm reduction based floating support models used in the United States are able to promote and sustain stable living arrangements and ensure contact with services ( Chapter 3).

* Homeless people with substance misuse problems have a range of needs that can include support with daily living skills, a requirement for mental health services and a requirement for support in managing substance misuse. Their needs are often complex and services that focus on any one element of their need, be it substance misuse, mental health or housing related support, meet with less success than services that are designed to support all their needs ( Chapters 2 and 3).

* There are three main models of resettlement for homeless people with a substance misuse problem. The first, the Continuum of Care or 'Staircase' approach, uses a series of shared supported housing settings that are intended to slowly progress service users towards independent living and abstinence. The evidence is that this model meets with limited success. The second, which is referred to in the US as the 'Pathways' Housing First model, uses intensive floating support to ordinary accommodation, with a strong focus on service user choice and a harm reduction approach to substance misuse. There is evidence that this is more successful and cost effective than the first model. The final model is a package of floating support provided through case management and joint working, which is the standard practice across Scotland. The evidence base on this approach is less developed than for some other models, though it follows the logic of both the flexible packages of support and harm reduction methods used by the more successful services ( Chapter 3).

* There is no strong evidence on the effectiveness of preventative services to counteract potential homelessness among people with a history of substance misuse. Most models of prevention are generic, i.e. they are intended to counteract the risk of homelessness across many groups, including people with a history of substance misuse, rather than being particularly focused on one group ( Chapter 3).

* The evidence base on alcohol misuse by homeless and potentially homeless people was very rich until the early 1980s when street drugs started to become much more widespread among street homeless and other homeless populations. Most research since that date has tended to focus on all forms of substance misuse, rather than dealing solely with alcohol, with the result that there is little recent evidence on services for homeless people that focus only on alcohol misuse. There is some evidence of older street homeless and hostel dwelling populations (people over 50) being more likely to be misusing alcohol and less likely to be using street drugs. However, among younger homeless people, the evidence is of use of alcohol alongside street drugs and other substances ( Chapter 2).

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