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Context More than 350 communities in the United States have committed to ending chronic homelessness. One nationally prominent approach, Housing First, offers early access to permanent housing without requiring completion of treatment or, for clients with addiction, proof of sobriety. Methods This article reviews studies of Housing First and more traditional rehabilitative (e.g., “linear”) recovery interventions, focusing on the outcomes obtained by both approaches for homeless individuals with addictive disorders. Findings According to reviews of comparative trials and case series reports, Housing First reports document excellent housing retention, despite the limited amount of data pertaining to homeless clients with active and severe addiction. Several linear programs cite reductions in addiction severity but have shortcomings in long-term housing success and retention. Conclusions This article suggests that the current research data are not sufficient to identify an optimal housing and rehabilitation approach for an important homeless subgroup. The research regarding Housing First and linear approaches can be strengthened in several ways, and policymakers should be cautious about generalizing the results of available Housing First studies to persons with active addiction when they enter housing programs.

Context Marijuana smoke is very similar to tobacco smoke, but whether it has similarly adverse effects on pulmonary function is unclear. Objective To analyze associations between marijuana (both current and lifetime exposure) and pulmonary function Design We used repeated measurements of pulmonary function and smoking collected over 20 years in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Mixed linear modeling was used to account for individual age-based trajectories of pulmonary function and other covariates including tobacco use, which was analyzed in parallel as a positive control. Setting 4 US cities, 1985–2006 Participants Black and white men and women recruited at age 18–30 years and followed for 20 years Main Outcome Measures Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) Results Marijuana exposure was nearly as common as tobacco exposure, but was mostly light (median 2–3 episodes per month). Tobacco exposure, both current and lifetime, was linearly associated with lower FEV1 and FVC. In contrast, the association between marijuana exposure and pulmonary function was non-linear (p<.001): at low levels of exposure, FEV1 increased by 13 ml/joint-year (95% confidence interval (CI): 6.4 – 20) and FVC by 20 ml/joint-year (95%CI:12 – 27); but at higher levels of exposure, these associations leveled off or even reversed. The slope for FEV1 was −2.2 ml/joint-year (95%CI:−4.6 – 0.3) at >10 joint-years, and −3.2 ml per marijuana smoking episode/month (95%CI:−5.8 – −0.6) at >20 episodes/month. The net association with FEV1 declined to or below baseline with very heavy use, but FVC remained significantly elevated in even heavy users (e.g., 76 ml [95%CI:34 – 117) at 20 joint-years). Conclusions Occasional and low cumulative marijuana use was not associated with adverse effects on pulmonary function.

Objective To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration. Design Observational evaluation. Setting Veterans Health Administration. Participants 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014). Main outcome measures A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death. Results 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n = 799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months. Conclusions Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient’s perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.