Housing Policies and their Impact on Engagement in Substance Use Treatment and Overdose Risk during the COVID-19 Pandemic

Project Summary Substance use disorder (SUD), overdose risk, and housing insecurity have reached crisis levels in the US. In 2019, over 8 million individuals met criteria for SUD, and nearly 37 million households were spending more than 30% of their income on housing. Since the start of the COVID-19 pandemic, already-high overdose mortality rates soared, and millions of households have fallen behind on their rent. Beyond initiatives focused on people without housing such as housing first, there has been a paucity of research focusing on the intersection of SUD and housing insecurity. Even less is known about whether policy attempts designed to support housing security have the potential to improve engagement in substance use treatment and reduce fatal and non-fatal overdose. Innovative housing policies enacted during the COVID-19 pandemic-including eviction moratoriums, emergency rental assistance, and legal representation to tenants facing eviction (right to counsel)-offer an unprecedented opportunity to fill this vital knowledge gap. Widespread variation across states in whether and how these policies were implemented allow them to be rigorously studied using causal methods with mechanisms and potential mechanisms explored using qualitative approaches. In Aims 1-2, we will conduct a 50-state study using a difference-in-differences approach to examine the effects of the three housing policies of interest on rates of substance use treatment and fatal and non-fatal drug overdose. Data sources for Aims 1-2 will include 50-state administrative databases capturing services delivered in the general medical sector (IQVIA LRx/Dx and HCUP) and specialty addiction treatment sector (TEDS), as well as CDC fatal drug overdose data. In Aim 3, we will conduct in-depth qualitative interviews with people with recent histories of drug use as well as providers and policy officials in urban and rural counties. Our study will yield actionable evidence to inform policy development and implementation at the intersection of housing and SUD designed to enhance engagement in addiction treatment and prevent drug overdose.