Behavioral Health and Drug Addiction..The Ignored Stepchild of Homeless Services

Various numbers have been reported that claim to total the spending on homelessness in Multnomah County.  They include the costs of shelters, clean-ups, supported housing, street outreach, and similar services.  But they do not include the cost of treating addiction and mental illness among the homeless (see Portland Voice Report #4).  At the governmental level, the issue of behavioral health (BH) problems and drug addiction among the homeless is downplayed or even ignored.

This is even reflected in the statistics the government publishes.  The typical report from the Joint Office for Homeless Services will divide the homeless population into about 15 categories of ethnicity and 5 categories for gender.  But any and all behavioral health problems, from long-term drug addiction to severe schizophrenia to mild depression, are listed under the one catch-all category of “Behavioral Health”.  The government does not even try to keep track of the BH problems of the homeless population, much less attempt to plan for and provide the vital services they require to recover from them.

This neglect is rooted in the financial and policy structures.

BEHAVIORAL HEALTH FUNDING

By statute, BH services are the responsibility of the county. These services fall under the county Health Department, comprising about 23% of its budget. But most of that goes to funding BH programs for schools, prisons, and the general population. Very little is direct funding for BH services for the homeless.

The BH providers that do serve the homeless are not compensated by the county Health Department or the Homeless Service Department but fund themselves through charity or from the state through Coordinated Care Organizations (CCOs), which in turn are funded through the state’s Medicaid program (the Oregon Health Plan, OHP).

Bar chart of MultCo and Portland Govt Homelessness Budgets for FY2025

Because the funding comes from charity or from the state through the OHP, there is little or no coordination with either the county’s health department or the county and city’s homeless service departments (see below, Gaps in the System).

What does the county spend on BH for the homeless? The only funding the county does provide is for the Behavioral Health Resource Center and a few other programs. It is a tiny part of the county’s Health Department budget, a bureaucracy that is separate – and siloed – from the homeless services bureaucracies.

So in FY 2025, the city and county homeless services organizations budgeted 3 times as much for their overheads as the county budgeted for behavioral health programs for the homeless.

CURRENT HOMELESS SERVICES POLICY

Bureaucracies naturally focus on their funding streams. Since a large part of the funding stream for homeless services comes from Metro’s housing taxes, the Homeless Service Department’s policies focus on housing.

In theory, the homeless are supposed to move into shelters and then move to supportive housing…an apartment or room with regular visits from social workers and other professionals who help them transition from the street into a regular living situation.

However good this might sound in theory, in practice, the current policies are only appropriate for many of the short-term homeless and the “at-risk” population. Most of the supportive housing does not offer the intensive support needed by the chronically homeless drug addicts and recovering addicts, nor for the seriously mentally ill. And housing providers, their insurance companies, and their residents do not want active drug addicts or people with severe mental health problems in their buildings, so they stay on the street.

The performance metrics used by the Supportive Housing bureaucracy reinforce this. “Success” is measured by the number of people housed and how long they stay in the housing, which sounds reasonable. But the fall-out rate among addicts is high, if they can be placed at all. Therefore, and in line with the incentives built into the performance metrics, most of the supportive housing effort goes into housing the “at-risk” population, who typically have fewer chronic problems and are therefore easier to “support” and place. Only 11% of supported housing placements are to people from shelters…those who are truly homeless. While this is justified as helping people who might become homeless, no data is offered indicating that this is the best way to spend the money.

It is worth noting that the county calls its program “Housing First”. But it seems to be only a shadow of the real, nationally recognized Housing First program, which matches individuals with the level of support and care that they need as they progress away from homelessness.

GAPS IN THE SYSTEM

What do the chronically homeless addicts need to begin their path to recovery? (and what is falling through the cracks in the system?)

From interviews with addiction-recovery service providers, people recovering from addiction need to go through several stages before they are ready for the kind of supportive housing the county provides. These start with the sobering and withdrawal process, followed by treatment and recovery. While the exact facilities needed and length of time depend on the individual, the early stages often require 24/7 inpatient care. Treatment and recovery often require intensive outpatient care, or “transitional housing”. While sobriety and recovery take 2-6 days, the later stages can take weeks or months, even over a year. Only then can they successfully transition to the county’s “supportive housing”.

The problem is that transitional housing requires specialized facilities and staff, while the staff for county-funded supportive housing is usually comprised of regular social workers working regular hours with limited training in handling the medical and psychiatric issues of withdrawal management.

The all-too-frequent governmental response to addiction among the homeless

There are few facilities that can offer these transitional housing services. Those that do are funded by Medicaid or private charities, not by the homeless service departments. And while the county’s health department has a legal requirement to fund the full continuum of addiction treatment, it spends very little on this vital link in the chain. And, as mentioned above, the health department is bureaucratically siloed from the homeless services agencies. There is little coordination.

The result is that there is a shortage of withdrawal/detox beds, and an even more severe shortage of transitional housing beds. Addicts attempting recovery fall into a gap. It is hard enough to find detox/withdrawal spaces. Then, those who do finish the very difficult several days of detox have few options for the transitional housing they need. The wait list is typically between one and eight weeks. There is no system to help them find a good placement…their case workers must call around to each facility they know of to ask if a bed is available. The newly clean addicts frequently wind up back on the street or in shelters while waiting. They are hard to locate when a bed does become available, and they are back in their previous environment, where the prevalence of drugs causes them to quickly relapse.

SUMMARY  

A large percentage (estimated at 70% to 80%) of the chronically homeless suffer from drug addiction and/or mental health problems. While those problems might not have been the cause of their homelessness and may have developed while on the street, these problems severely limit their ability to successfully transition out of homelessness.

But the city and the county homeless services departments spend little to address BH problems among the homeless population. At a policy level, they almost seem to brush it aside. Instead, we spend a fortune on police, fire, and hospitals to deal with the “collateral damage”. And that does not even begin to address the impact on the city’s quality of life, reputation, and tax base.

Current policy is to put all the homeless into housing as quickly as possible, whether or not sufficient support is available. But we must be honest: unless you are set up to handle them, and few are, nobody wants to let homeless addicts into their buildings. Instead of recognizing and providing for their needs, we have built a system that shunts them off to the side, effectively ignoring them.

We cannot afford to let so many difficult cases stay on the street, ravaging themselves and the city.