Large majority of homeless people in California are not illicit drug users, study finds

A large majority of people living on the streets in California are not illegal drug users, a study found. But drug use is still deeply intertwined with homelessness, both as a risk factor and an effect of losing housing, the researchers wrote.

The study, published in the medical journal JAMA by the Benioff Homeless and Housing Initiative at UC San Francisco, gives a complex statistical picture of a topic that has been fraught by conflicting narratives. Against a public perception that drug use is endemic to homeless camps, service providers and advocates see an exaggerated reaction to open drug use on the street that stigmatizes the majority of homeless people who do not use drugs.

The Benioff study supports some elements of both viewpoints. Contrary to common perception, only about 37% of homeless people were using illicit drugs regularly, and 25% said they had never used drugs. But drug use is far more prevalent among homeless people than in the general population. Just over 65% reported having regularly used at some point in their lives, and 27% had started after becoming homeless.

Another twist: 35% of respondents said their drug use had decreased after they became homeless. Some were parents worried about losing custody of their children. Others had “just reached that point,” said lead author and Benioff director Margot Kushel.

That finding highlighted the need for better treatment options, Kushel said. Many told interviewers that had already cut back and would like help to cut back more.

“One of the most poignant findings was that 1 in 5 told us they are actively seeking treatment and couldn’t get it,” Kushel said in an interview.

In-depth interviews illustrated their frustration, Kushel said, with respondents saying, “I’m showing up where they tell me to show up, calling where they tell me to call,” only to be turned away.

Only 7% of those with any lifetime use said they were receiving treatment.

“Its hard to get treatment,” Kushel said. “It shouldn’t be. You shouldn’t scrounge to save money to go somewhere and be told you’ll be put on a waiting list. That should not happen, but it does.”

Housing is the solution, Kushel said, but until enough of it is available, there is a need to bring more resources to the street, such as methadone or other medications that treat opioid addiction.

Kushel also urged increased access to residential treatment as long as it could lead to housing and that those who relapse in treatment — “very common and part of the natural history of substance use disorders” — would not be returned to homelessness.

The report, Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness, is one of a series of reports based on Benioff’s 2023 Statewide Study of People experiencing homelessness. The largest representative sample of homelessness since 1990s, it consisted of 3,200 questionnaires and 365 in-depth interviews.

Prior Benioff reports based on the survey have covered intimate partner violence and pathways to homelessness.

Unlike the 1990s survey, which included only people using homeless services, Benioff canvassed both shelters and encampments, noting that homeless patterns had changed, with a higher proportion unsheltered, and drug preferences in the general population had shifted from cocaine to methamphetamine and fentanyl.

The new report found that methamphetamine was, by far, the most used drug on the street.

“People are telling us that it helps them survive,” Kushel said. “It keeps them awake and alert. They are using it either because they are traumatized, they have been assaulted, they are afraid or depressed, using it as coping to make it all go away.”

Only about 10% of respondents said they were regularly using opioids, most mixing them with methamphetamine. But even intermittent use, or unwitting use through contamination, poses a high risk of death. Just under 20% had experienced an overdose in their lifetimes and 10% in their current episode of homelessness.

About a quarter reported having naloxone, a medicine that reverses an opioid overdose, but Kushel said it should be in the hands of every opioid user and everyone around them.

“What we’ve heard from a lot of people is, ‘I’ve seen an overdose,’” she said. “You can’t often wait for a first responder.”

Despite the high lifetime use of cocaine, at 58%, only 3% said they were currently using it.

“Like a lot of things we talk about in medicine, some things get worse, some things get better, some things stay the same,” Kushel said.