Social Work Assistance and Stipends for Housing (SASH):
Improving Outcomes for Homeless ​Patients Receiving Methadone for Opioid Use Disorder
Project Lead: Max Spaderna, MD
Background
Patients receiving medications for opioid use disorder (MOUD) experience high rates of homelessness. Providing housing assistance for both temporary and permanent housing could improve outcomes for housing and opioid use disorder (OUD) treatment. Social Work Assistance and Stipends for Housing (SASH) was a 12-month pilot study investigating the feasibility of providing a housing intervention to unhoused participants who were receiving methadone as a MOUD.
Methods
SASH engaged a convenience sample of eight participants receiving services through an addiction treatment program. Participants were eligible for six months of $650 housing stipends that could be used for temporary and permanent housing, along with 12 months of intensive social work team assistance to obtain housing. Providers were initially graduate school social work interns, and when they graduated from their social work programs after six months in the study, they were replaced with community health workers at the addiction treatment program. To measure OUD outcomes, the OUD Checklist (drawn from the DSM-5 criteria for OUD) was used along with results from participants’ urine toxicology tests. At months six and 12, participants completed qualitative interviews discussing their OUD treatment, housing assistance, and experience taking part in SASH. A thematic analysis of the interview transcripts was completed.  
Results
One participant was removed soon after entering the study because the participant was housed through another recovery program. Six participants completed qualitative interviews at month six, and five participants completed interviews at month 12. Participants’ OUD scores at each month six timepoint were consistent with severe OUD. Of those whose housing status was known, four were housed and two were homeless at month six, and three were housed and two were homeless at month 12.
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The thematic analysis identified several themes. Participants described SASH as a valuable and enjoyable experience, with improvements in self-efficacy evident from interview responses. As one participant explained, the study showed that “if we apply ourselves and take the time and put the good foot forward, as they say, good results happen.”
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SASH also found success obtaining housing for participants by connecting them with citywide housing resources and through working with community health workers that provide case management to all the clinic’s patients. As one participant explained:
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"Basically, because of this study, I went into a shelter, and the shelter entered me into a system, and they found a temporary housing program for me. I'm also still in the system, and I might be able to get permanent housing."
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Participants reported that SASH program components and the experience overall improved their methadone treatment. One participant cited advice from social work interns to receive take-home methadone. “I did it, and it worked out for the best, and I was able to get the bottles [of methadone].” Participants also credited SASH with decreasing their desire to use substances. One stated that the program “caused me to use less and less frequently because I've had something to focus on other than just using drugs and getting me something to look forward to.”
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Though participants described these and other SASH benefits, they also reported challenges related to the stipends and social work assistance, including that social work interns needed more knowledge about available housing resources. As one participant explained, the interns were “super great with the resources that they had,” but they “just needed a little bit more to go off of.”
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Participants reported delays in receiving the stipends and concerns that the short-term period of stipend provision would prevent them from sustaining housing. As one participant explained after the stipends ended, “It helped me for the six months. But now, I don't know what I'm gonna do. It will take all of my disability to live there [her home].” Another participant who remained homeless at month 12 recommended not having the stipends be time-limited: “If it wasn't so sporadic, something more permanent, maybe, it would be better.”
Discussion
Results of this pilot study indicate that providing financial assistance along with support from providers to access stable housing could benefit unhoused patients receiving MOUD. A more agile payment system capable of dispersing money for temporary housing is needed, and six months of financial assistance does not appear sufficient for patients who face multiple barriers to obtaining stable income. It appears that because case management was the primary activity of providers within this model, community health workers were better suited to delivering this service. Peer recovery workers may be optimally qualified for this role because of their lived experience and the trust this facilitates with the people they help. Having the same provider for the duration of the intervention would also be important for future iterations. Overall, the study demonstrated the promise of intensive support to navigate housing systems and access housing available to patients receiving MOUD. Future studies should investigate how best to connect unhoused patients receiving MOUD with available housing resources.
Table 1: Qualitative Interview Questions for Months 6 and 12 
Table 2: Demographics and Quantitative Results
Figure 1: Thematic Analysis of SASH Qualitative Interviews
