Which Came First
When we see someone struggling on the street, we tend to assume addiction is why they are there. Sometimes it is. But for a great many people the order runs the other way.
The most common explanation we give is the drinking, or the pipe, or the needle. It's not a crazy one. The cases we notice most are usually the ones where the struggle is written all over someone.
But the most visible cases and the most common ones aren't the same thing, and neither one tells you which came first. A person can be both addicted and homeless without the addiction causing the homelessness. The order is a fair question, and it has a real answer.
The drugs are real. The question is whether they came before the street, or after it.
The part that's wrong is easy to miss.
The belief goes like this: people end up on the street because of what they put in their bodies, and the fix is to get them to stop. It comes from what we see, and from an understandable human instinct that people tend to land where their choices put them.
Some people did lose their housing in the wreckage of an addiction that came first: the job gone, the family worn thin, the savings spent, the lease lost.
But the belief takes for granted that the drugs came before the street. For a large share of people, that order is simply backward.
No one has run the definitive study here in Buncombe County, so the best evidence comes from a study in California. It is the largest of its kind in decades, and it asked people directly.
Among the people surveyed who used drugs regularly, the most common drug was meth, and the next most common was opioids. Of those regular users, 42 percent said they began using that often only after they first became homeless. So for the 42 percent, regular use was not what first cost them their housing.
Why would regular use start only after someone becomes homeless? Because the street is hard on a person in the ways you'd expect. The cold that never fully leaves. The boredom that wears you down. The fear of closing your eyes in a place where closing your eyes is dangerous. The plain exhaustion of never once being safe. People turn to whatever can dull all of that. On the street, what's easy to get is rarely good for them.
Researchers have a dry name for it, social adaptation, and a gentler one, self-medication. Both describe the same thing: a person trying to get through something unbearable with the only tools within reach.
Cause and effect run in both directions. For many people, addiction is part of why they fell. For many others, it's part of what the fall did to them. Often it's both at once, each one feeding the other. It is not, for most people, as simple as choosing drugs over a home.
The first figure is ours. The other two come from California.
The other half of the picture in our heads is the part where help is offered and refused.
In that same California study, of the people using drugs regularly or drinking heavily, one in five currently wanted treatment and could not get it. Not refused it. Could not get it.
The people interviewed described the barriers: no openings, long waits, staff who didn't respond to their needs, and treatment too far away. They also described how the moment a person is finally ready can be the moment nothing is available. Readiness doesn't last long. We've built a system that mostly misses it.
Which is why "get clean first, then we will house you" isn't the plan it sounds like. It assumes a person can quit while still homeless. Someone sleeping outside has no door that locks, no address, no safe place to keep medicine, and a waitlist that's much too long. For that person, "get clean first" is a softer way of saying "not yet."
A home is not a cure.
Hand someone the keys and the addiction doesn't vanish. The biggest trial of housing people first followed 2,148 people with a serious mental illness in five Canadian cities. Housing them first kept far more of them in stable homes than the usual services did. Their drug and alcohol problems improved about as much either way.
Housing is the starting point. Many of the people interviewed for the California study said housing would help them get treatment. You don't detox in a tent. Recovery needs sleep, a door, a place to keep your medicine, a phone that stays charged, a reason to try. The street takes every one of those away. Get someone inside, and they have a better chance to fight the addiction.
Get the order right.
Addiction among our homeless neighbors is real, and it deserves treatment that exists and that they can get into. But seeing it as the cause of homelessness gets the order backward for a great many people. Many regular users didn't start using that often until after they first became homeless, and homelessness made it hard to cut down or stop.
So if someone's been homeless a long time and they use drugs regularly, drink heavily or live with a serious mental illness, the better way to help is not to wait for them to fix themselves while they're still on the street. It is to get them inside, where recovery can start, and to make treatment something a person can actually get on the day they ask for it. Help offered late, on impossible terms, isn't really help.
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