Monday, May 20, 2013

Critique of Prescription Drug Monitoring Programs--Charlie Jose

Since the 1990s, Opioid-related overdose deaths have increased dramatically in the United States (Paulozzi, 2006). In Massachusetts alone, opioid-related overdose deaths have exceeded motor vehicle crash-related deaths since 2005 (CDC, 2011). Many factors have contributed to this increased mortality, which include: new drug use patterns, greater heroin availability, more potent heroin composition, as well as increased abuse of prescription medications (Shah, 2008).
Numerous strategies exist to reduce the rate of opioid-related overdose deaths, as well as opioid-related harm. In Canada, established safe injection facilities, where drug users can use pre-obtained drugs under supervision, have reduced mortality in drug-using populations (Marshall, 2011). Prescription Drug Monitoring Programs (PDMPs) have been established in numerous states to reduce prescription drug diversion and the act of “doctor shopping” by drug users seeking access to opioids (Office of NDCP, 2011). While PDMPs are useful in reducing use of non-prescribed medications, there is no data to support their efficacy in reducing overdose-related deaths and harm (Paulozzi, 2011).

Overview of Critique: Isolation and Hopelessness Caused by Prescription Drug Monitoring Programs (PDMPs)
This critique will address the vast limitations of PDMPs. While these programs can minimize access to prescription opioids, many skeptics criticize the role PDMPs play in reducing opioid-related overdoses and harm (Green, 2011). Particularly, this approach does not address social and behavioral considerations sensitive to drug users, which have the most effect on reducing mortality.
Although PDMPs generate databases help physicians identify risky patients likely to abuse opioids, the resulting actions taken by physicians contributes to the social stigmas and labels that can fuel drug use. When physicians deny drug-seeking patients in clinical settings, psychological reactance triggered by the authority of physicians can lead to worse health outcomes. As PDMPs place interventional control with health care professionals and not the drug users themselves, this strategy diminishes a patient’s sense of self-efficacy.
Overall, PDMPs instill a sense of anger and hopelessness among drug users. These individuals most often need more support than the average citizen. For this reason, PDMPs are not effective in reducing opioid-related overdose and harm.

Adding a Label to a Heavily Stigmatized Population
In some states, law enforcement can become involved with PDMPs. This can lead to sanctioning for drug seeking patients that highlight the illegality of “drug shopping.” Simply put, this adds a negative label to an already heavily stigmatized population.  National campaigns and community-based programs teach society from a young age to avoid drugs, creating a societal norm that drug users are “bad people.” This has created a social stigma surrounding drug users, who do not adhere to the social norms of living a drug-free lifestyle and further become ostracized from society (Goffman, 1963). In the case of opioid use, growing stigma in receiving medical treatment affects the receipt and access of health care (Latkin, 2013). In some cases, stigma can lead to worse health outcomes, such as severe depression and isolation of drug users during treatment (Cornford, 2012).
PDMPs enable health care professionals to negatively label drug users as deviants of common societal norms, as supported by Labeling Theory (Mead, 1934). Patients seeking prescriptions are already dealing with the stigma of being a drug user, now they are branded and labeled as criminals in the clinical setting. Drug users are left with no choice but to believe they are in fact criminals, which embellishes their existing social stigma. This malicious cycle defeats the original purpose of PDMPs to reduce opioid-related harm, as depression caused by stigmas and labels can lead to even more drug use (Chen, 2013).
Both stigmas and labels affect the overall well being of an individual. Specifically, the negative nature of these elements diminishes the self-esteem of drug users. According to the Hierarchy of Human Needs, depressed individuals who lack self-esteem neglect the value of their personal health (Maslow, 1943). In the case of drug users, being healthy is defined by society as abstaining from drug use altogether. Maslow cites that lower levels of human needs, such as the desire for respect, positive recognition, and confidence, must be satiated before an individual can even start considering the importance of health. Since society does not condone drug use, confidence and self-respect become impossible to attain.  The idea of being healthy and free from drug use far surpasses the daily concerns of opioid users. As a result, these individuals turn to drugs in order to cope with the negative attitudes and feelings caused by societal stigmas and labels. Drugs provide validation when society (through the implementation of PDMPs) rejects drug users for their deviation from cultural norms.

Psychological reactance fueled by physicians
Doctors serve as the key players who allow this program to actually have an effect on reducing overdose deaths and opioid-related harm. They review PDMP databases and decide whether or not they will prescribe opioids to patients.
More importantly, the way in which a physician delivers a rejection to drug seeking patients determines the effectiveness of this intervention. When a doctor denies a drug seeker in the clinic and counsels the patient about their drug use, Psychological Reactance Theory explains that being told “no” can have a worse outcome for the patient. This theory states that when a person experiences a threat to their personal freedom, they react in a way that motives them to restore their autonomy (Brehm, 1966).
Specifically, the dominance exerted by the physician, who serves as a figure of authority over the patient’s health, magnifies the psychological reactance of the message (Dillard, 2005). Denial of prescription drugs instills anger and rebellion among patients, which leads to negative health outcomes and further fuels their drug use (Blose, 2009). A doctor in a position of authority simply does not have the characteristics that give a drug user the ability to relate. Although physicians are trained in counseling as part of their medical education, drug counseling and addiction treatment takes a unique skill that requires specific training, especially in the case of opioid users (Joe, 2009).
Unfortunately, not all primary care physicians at the front lines of PDMPs receive this training, which has negative consequences in the ability for this program to achieve its goals of reduced harm. How doctors approach their patients matter in order to reduce overdose deaths, and most often, confrontation does not work (Miller, 2007).

Taking Control Away from Drug Users
The inherent design of PDMPs takes away any control that drug users have in curbing their drug use and reducing opioid-related harm. As health care professionals are the primary mode of intervention and hold the choice of providing prescription opioids to patients, control is shifted away from drug users themselves in managing their own drug use. According to the Theory of Planned Behavior, there is a trickle down effect on to the individual’s level of perceived control (Ajzen, 1991). Since control is stripped away from the drug users, they are instilled with the idea that they are helpless in controlling their own fate.
According to Edberg (2007), if someone does not have perceived power, they will be less likely to take action (where “action” in this case means controlling one’s drug use). For the extent of their drug use, drug users have been told that their addiction has taken away their control of their ability to curb their habits. Now, a health care policy has codified their lack of control. Utilization of PDMPs subliminally harps on a drug users perceived lack of control, which is harmful if society expects drug users to help themselves.
Not involving patients in the process of reducing their own drug use has negative consequences among heroin users (Cornford, 2012). Specifically, hopelessness can lead to more drug use. To get drug users to want to help themselves, they must believe that they have control. The authority of doctors serves to impede a patient’s sense of self-efficacy, which is an individual’s measure of their ability to complete tasks (Ormrod, 2006). If drug users are not instilled with the notion of control, they cannot take action to stop their own drug use.
Proposed Alternative Intervention: The Power of Overdose Education and Naloxone Distribution (OEND) Programs
Implementing Overdose Education and Naloxone Distribution (OEND) programs for drug users and bystanders is a cost-effective strategy to prevent and manage overdoses (Coffin, 2013). This strategy has even shown to reduce opioid-related deaths in some communities (Walley, 2013). As part of OEND training, participants are educated about overdose prevention, recognition, and response – critical skills required to manage an overdose situation. Participants are also given Naloxone, which counteracts the life threatening respiratory depression that causes death. Unlike PDMPs, OEND programs address behaviors and prevention strategies at the individual drug user level. OEND programs work by changing social norms to counter the isolation and depression caused by social stigmas and labels. The effectiveness of OEND programs comes from the fact that those delivering the intervention are laypersons that are more relatable to a drug user than doctors and pharmacists. Most importantly, OEND programs impart a sense of control among drug users, which develops the ownership necessary to combat his or her drug use habits. A sense of control is further spread through OEND trainees’ social networks.

Changing Social Norms
Instead of isolating drug users who may not adhere to standard social norms, society can change social norms in a way that reduces opioid-related harms. Changing the role that drug users play in society can counteract the burden that social stigmas and labels place on these individuals. Although society has set rules and patterns that are considered “normal,” individuals have the ability to change what is socially accepted as described by Social Expecations Theory (DeFleur, 1989). Rather than ostracizing drug users as criminals, which fuels their associated social stigma, OEND programs accept drug use as part of the healing process. Enrollment into OEND programs changes the way people, who may or may not be a drug user themself, view a drug user. OEND programs put laypersons on the front lines of reducing opioid-related harms, which develops a sense of familiarity with this heavily stigmatized group. Unlike national campaigns targeting drug use, these programs impart a sense of community among all members of society. Instead of labeling these people as criminals who are “below” society, OEND programs highlight that drug users are peers who also need help.
By fostering a sense of camaraderie, overdose education and even the distribution of naloxone has shown to reduce the number of deaths caused by overdose (Walley, 2013). While there are only 16 states with established OEND programs, Diffusion of Innovation shows promise for this initiative to reduce opioid-related harm.  Adoption of innovation is a process (Rogers, 1962). As more people enroll in OEND programs and reverse potential overdoses, society’s perspective about drug users can positively change. This changes comes from the confirmation of the value of OEND programs and from the developed familiarity about drug user behaviors. As more people become involved in preventing harm, the overall views of society change to extinguish the overly emphasized criminality of drug use.

The Message of OEND Programs Comes from Similar People
OEND programs are comprehensive, in that they involved all people in the process of curbing overdose-related harm. Anyone can be trained through OEND programs – family members, bystanders in overdose situations, even drug users themselves. This feature allows all people to take part in managing overdose-related harm, not just physicians and pharmacists. As described by Silvia (2005), consideration of who delivers a message is important when implementing a program.
When the person relaying the message is similar and more relatable to the audience, there is less psychological reactance experienced compared to when someone estranged relays the message (Silvia, 2005). Power and influence is removed from health care professionals and disseminated to people who are familiar to a drug user. In some cases, other drug users become the messengers to their fellow drug users in reducing overdose deaths (Doe-Simkins, 2009). Family members, bystanders, and drug users are much more relatable to a typical drug user than an authoritative doctor. For this reason, OEND programs reduce the effects of psychological reactance so that drug users are less resistant to overcoming the problems caused by their opioid use.
The added bonus of increased ability to measure psychological reactance in OEND programs compared to PDMPs also allows overdose education and naloxone distribution to be more effective. As researchers have developed ways to measure the knowledge provided by OEND programs as well as the attitudes of recipients of treatment, they are able to specifically tailor how these programs can better deliver their message (Williams, 2013). This contrasts the limited data on psychological reactance data of PDMPs, since it is hard to follow patients denied of prescriptions to ask them about their personal reactions and patient satisfaction.

The Social Networks of OEND Trainees can Spread the Idea of Control

The most important lesson taught by OEND programs is that family members, bystanders, and drug users have the ability to control the fate of themselves and their loved ones using drugs. According to Prospect Theory, people take ownership of things and think they have control when they have a better sense of the risks involved (Kahneman, 1979). Therefore, it is important for society to give back ownership to drug users about their own problems and issues. By teaching trainees how to manage overdose and reduce potential opioid-related harm, OEND programs instill a sense of confidence that was otherwise taken away by society through the implementation of PDMPs (Strang, 2008). Doctors and pharmacists are no longer the gatekeepers in managing opioid-related harm. OEND programs provide buy-in to all members of society, most importantly to drug users themselves, in determining their fate. The OEND strategy gives drug users a stake in reducing opioid-related harm.
The all-inclusive nature of OEND programs compared to PDMPs also provides a powerful benefit. As noted by Social Network Theory, behaviors spread through social networks, not through individuals (Wasserman, 1994). The social circles of OEND trainees are much more expansive than doctors and pharmacists alone. Most often, the social circles of family members, bystanders, and drug users trained in OEND better reach target populations that have greatest control in reducing opioid-related harm (Walley, 2013). As individuals trained in OEND are most likely to be the support system for drug users, these programs strategically target individuals who have the most influence in the behaviors of drug users. This has a more advantageous effect than PDMPs, where health care professionals are the key players in intervention strategies.

Opioid-related overdose deaths and harm continue to be a major issue haunting the United States. Especially with the growing rate of prescription drug abuse, it is important to develop interventions that can reduce harm. While Prescription Drug Monitoring Programs have the ability to restrict access to addicting prescription drugs, this strategy contributes to the social stigmas and labels that burden drug users and that can contribute to greater use of drugs. Not only do these programs take personal control away from drug users, the messenger in PDMP interventions is not relatable to a drug user.
Overdose Education and Naloxone Distribution Programs provide social support that helps alleviate the oppression caused by societal norms. OEND programs achieve this aim by focusing on individual-level intervention and by helping combat social stereotypes associated with drug users. This alternative strategy helps develop the confidence and self-efficacy needed to help drug users help themselves.


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The Emergency Assistance Shelter Crisis: Reducing Social Stigma and Promoting Advocacy in Massachusetts’ Homeless Families - Latoya Lashley

In Massachusetts, there are approximately 3,800 homeless families with pregnant women and children in the Massachusetts Emergency Assistance (EA) shelter program (1). Historically, Massachusetts’ extensive state-funded emergency shelter program is maintained through EA. In summer 2012, Massachusetts began restricting funds to EA shelters to fund affordable housing and homelessness prevention instead. There is a belief these reforms will better serve families, providing new resources for them to get back on their feet and on their way to self-sufficiency while maintaining a key safety net for emergencies. However, these efforts to end family homelessness have resulted in unintended consequences that hurt the very population they are meant to help.
Although the long-term effort to fund affordable housing and prevent homelessness is valid, it does not eradicate the immediate issue of families already homeless with nowhere to go. Along with promoting the stigma of homelessness, Massachusetts’ recent policy change precipitously restricts access to emergency shelters. This sudden decline in shelter access denies the basic needs of families struggling to stay afloat and places a burden on health services working tirelessly to support these families. To begin to resolve this issue will require a change in current policies as well as helping families fulfill their basic needs by teaching them to be advocates for themselves.

In January 2008, the Massachusetts Commission to End Homelessness released a comprehensive five-year plan to eliminate homelessness in Massachusetts (2). As a result of this report, the responsibility of EA was transferred from the Department of Transitional Assistance to the Department of Housing and Community Development (DHCD). In addition, the Deval Patrick administration proposed to restrict EA shelter access for fiscal year 2012 to only families that fit into narrow categories and not provide these families with any form of rental assistance but rather potentially refer them to a homelessness prevention program (3). These revised categories for EA shelter eligibility include: (A) families who are at risk of domestic abuse in their current housing or who are homeless because they fled domestic violence, (B) families who are homeless due to natural disaster, (C) families who are homeless because they have been evicted due to foreclosure or nonpayment of rent due to a disability or medical condition, and (D) families who have no tenancy of their own and are “doubled-up” with other households or are staying in a place not meant for human habitation (4).
The intention of these efforts are to satisfy the idea of “Housing First”: a model whereby moving homeless families immediately into permanent, affordable housing is the primary goal (5).Unfortunately, housing first is the last thing that is happening in Massachusetts. The problem: left out of these categories for EA eligibility is families at imminent risk of staying in a place not meant for human habitation (3).” In this case, if a family is in danger of becoming homeless they cannot access an emergency shelter. The family will have to spend the night is some place not suitable for human habitation, such an abandoned property or their own car, before they can be considered qualified for shelter. Thus, what was proposed and implemented as a safety net is actually leaving more people out of housing. Since September 2012, the application rate for EA shelter has increased from 40% last year to 75% and over one hundred families have been placed in shelter only after they slept in places not suitable for living (3). Shifting funding from vital EA shelters and using the “savings” to fund housing resources for other families has many consequences and is the focus of this critique.
Families Staying in Unstable Conditions Have Unmet Basic Needs  
Families are put at great risk because of the current state of homelessness left in the wake of recent reforms. To be eligible for EA shelter, children and their parents must “officially” become homeless. Even if a family is fortunate enough to find shelter it is still not a promise of better living. Oftentimes, the shelters can be overcrowded and dangerous. Yet, it is better to stay in a shelter despite these conditions because to leave the shelter system denies families many other shelter resources. Other families may find themselves housed in motels located on highways where there is no easy access to grocery shopping and little to no resources to cook a meal. Retired social work professor from Bridgewater State University and homeless advocate, Betty Reid Mandell, describes how some motels had roaches, lice, or rats. Couples on one-night stands, as well as prostitutes and pimps frequented some motels (6).
The effect with having children in such an inappropriate environment can be devastating. The chronic stress and deprivation associated with homelessness may have long-term effects on development and functioning (7). Maslow’s hierarchy of needs elucidates why the homeless’ motivations to achieve self-actualization or purpose in life is hampered. At the core of Maslow’s theory are two important ideas: (A) there are multiple and independent fundamental motivational systems and (B) these motives form a hierarchy in which some motives have priority over others (8).  At each level you can argue how Massachusetts EA shelter reform is preventing needs from being met for homeless families.
Unmet Physiological Needs
At the bottom of this hierarchy are physiological needs such as food, water, and sleep. If these requirements are not met, the human body cannot function properly, and will ultimately fail (9). Physiological needs are thought to be the most important and they should be met first. Without the satisfaction of lower order needs, individuals will not pursue higher order needs. Homeless families who are disadvantaged find it harder to achieve upward mobility in their life because all their attention is focused on lower order needs. Facing such irregular housing conditions places the entire family in a constant state of stress. A family denied shelter might not know where their next meal is coming from, where they can take a shower, or where they will rest their head at night. Families denied shelter are forced to sleep in overcrowded and stressful doubled-up situations, moving from place to place and missing school and work, all of which is upsetting for a child (3). Such situations can lead to increased behavioral and mental health problems.
Unmet Safety Needs
Safety needs include the security of body, employment, resources, health, and family (9). Because of EA shelter reform, families face living on the street because of the unwillingness of DHCD to provide emergency shelter access. The Massachusetts Law Reform Institute supports families facing this predicament. They come across families living in dangerous situations on a daily basis. One such case involved a woman and her 9-month-old baby who had originally stayed with three different acquaintances over the course of a week. Out of options, the woman turned to DHCD for assistance but was turned down because she was unable to get letters from her former hosts verifying her living situation. As a result, this woman and her baby stayed in South Station. Out of desperation to have a place to stay, this woman accepted the help of a stranger but ended up being raped by her supposed savior (3). For others living in motels, minor violations leave people facing the possibility of eviction. In one instance, a family was terminated from the shelter system because the mother and some of her family helped another resident with a sleeping baby carry some items into the resident’s room. This was in violation of the “no guests” rule (3). Such situations clearly reveal that current regulations make it impossible for the homeless to feel secure in their housing status.
Unmet Needs of Love and Belonging   
A need of love and belonging include friendship, family, and sexual intimacy (9).  According to Maslow, humans need a sense of belonging and need to feel loved (9). The desire to feel needed is especially strained when a family is moving from place to place among acquaintances that can no longer support you. Children face the reality of not having a place to call home. Also, the constant moving from place to place keep children out of school and away from their peers. With such inconsistent living conditions it is impossible for homeless families to feel like they belong. A community may exist in a shelter but strict rules preventing fraternization within shelter rooms greatly inhibit building a greater sense of community.
Unmet Need of Self-Esteem
Esteem presents the typical human desire to be accepted and valued by others. Maslow described two types of esteem: lower and higher. Whereas lower esteem is the need to have respect from others, higher esteem is the need for self-respect (9). Dealing with the system to find shelter can be a grueling and demoralizing process. Self-esteem can be low for a parent that feels humiliated by DHCD in front of his or her own children. Families often report feeling like DHCD is trying to get them to leave the office and does not want to help them (3).  These families do not receive the respect from the people they are appealing to help for. Without this lower level of esteem achieving a higher level of esteem or respect for oneself is difficult.
Unmet Need of Self-Actualization
Maslow described self-actualization as recognizing that each individual is fitted best to do something in this world and that individual needs to realize their full potential (9). Without having the resources to begin fulfilling the basic needs Maslow described in his hierarchy model, homeless families cannot begin to fathom what their purpose in life is. Their sole focus is on surviving and meeting those basic physiological and safety needs.
Without having basic needs met, homeless families or those facing homelessness do not have the motivation begin to pick up the pieces and move forward with their life. These concerns over unmet needs were voiced recently at a public hearing in Springfield, MA in October 2012 (10). Nonetheless, the DHCD declined to revise regulations to provide shelter to children and families at imminent risk of staying in a place not meant for human habitation (11). Thus, families will have to continue facing irregular housing conditions that deny fulfillment of basic physiological, safety, love and belonging, esteem, and self-actualization needs.
Promotion of Homeless Stigma
Another unintended consequence of Massachusetts’ Emergency Assistance shelter reform is the stigmatization of homeless families. A stigma is an attribute that spoils an individual’s identity (12). In particular, Erving Goffman describes a type of stigma that involves membership in socially devalued groups such as racial and ethnic minorities or gender (12). The homeless is considered such a socially devalued group that faces stigmatization from their fellow citizens (13).
Families are acutely aware of their sate of homelessness. With the new reform, those imminently facing homelessness will have to become homeless to be eligible for shelter. Once this happens these families take on the stigma of homelessness. It is all they can do to protect themselves from facing the harsh realities of being homeless. Coping strategies are needed to provide protection when dealing with people outside of their world.  Individuals may try to hide their stigma if it can be disguised, and limit its social impact on one’s identity (12). One coping strategy may be withdrawal by limiting one’s participation in society. This withdrawal does little to help a homeless family flourish.
There is a sense to blame the disadvantaged for their own predicament (13). Shelter programs are shaped by prevailing views of the poor, who are considered to be generally inadequate and incompetent and in need of reform.  In "A Roof Over my Head," Jean Calterone Williams expresses this well: “By making many aspects of their programs mandatory . . . shelters give the impression that homeless people will not take the initiative on their own to look for work or housing, enroll their children in school, or keep their living spaces clean. They must be forced to do so. By mandating budgeting classes, shelters suggest that people become homeless in part because they are irresponsible with their money. It is in a sense a symbiotic relationship: shelter programs influence the ways housed people think about homelessness, the views of the housed public - whether ordinary citizens or policymakers - affect the formation of shelter programs and how such programs treat homeless people” (14).  William’s words express a truth about homelessness: families facing homelessness or who are already homeless have lost control of their life oftentimes due to uncontrollable circumstances. Yet, the rest of society will view them as being at fault for their situation. This perception creates a stigma on the homeless as hopeless needy people that need direction in their lives.
Burden on Healthcare System
The changes in Massachusetts policy for housing the homeless has far reaching consequences. In recent months, the Massachusetts healthcare system has seen an influx of families in their primary care clinics and emergency departments. Boston Medical Center pediatricians have reported a 30% increase in homeless families arriving in the hospital (3). Families who would have previously been provided with a shelter prior to the policy change find themselves spending the night in the emergency department to satisfy the new criterion of spending the night in a place not fit for habitation (3). While a hospital can provide the health care families require, an emergency room is not the most suitable place for a family to stay. An emergency department is not appropriately equipped to provide food, sleeping, or bathing arrangements as a shelter can. Also, families are unnecessarily exposed to illness, which can compromise health. Furthermore, emergency departments can be overcrowded and do not have the staff or room to accommodate homeless families looking for shelter. And while emergency departments resorting to the last option allow families to stay overnight, other patients who are truly ill and require the resources of the hospital suffer.
The cost of treating a homeless family in the emergency department turns out to be more expensive than housing a family in a shelter (3). This disparity is driving up healthcare costs. The current model of providing medical care for these families and subsequently allowing them to stay overnight in hospital beds is financially unstable. It is estimated that the cost to take care of a family in the emergency room in 2013 averages around $334. These costs may increase if additional testing or inpatient care is required. Whereas the cost of housing a family in a shelter averages around $85 per night (3). Placing this burden on the healthcare system eventually ends up costing Massachusetts more money.
There is also a strain on staff working to find solutions for families in crisis. Boston Children’s Hospital social workers have reported a 50% increase in the social work hours devoted to helping homeless families since the new regulations took place (3).  Healthcare workers have become advocates for these families fighting DHCD to ensure families have someone to rely on but at a great emotional cost. Advocates become vested in fighting for these families. The frustration of the system working against the homeless can induce a great amount of stress for workers. Understanding that this policy has social, emotional, and economic consequences is important to begin combating the issue of homelessness in Massachusetts.
Proposed Policy Changes
In order to address the issues of the Massachusetts homeless housing crisis a solution requires a multi-faceted look at the problem of homelessness in the short and long term. Policy addressing the most urgent problems of the homeless crisis and long-term approaches to the underlying problem of homelessness is required.
For the short term it is vital to maintain access to emergency assistance shelters.  To achieve this goal will require the language in the current policy to be strengthened to include families in imminent danger of living in unsuitable conditions to be eligible for EA. In this way, families do not have to experience the fear and hopelessness of becoming homeless. New policy will also need to prevent denial of EA while trying to verify third party resources and end unfair termination from motels.
Beyond policy changes the people facing homelessness need to become advocates. Currently, legal services help families fight against evictions and to navigate the homeless system if they do lose their home. Such support should continue. Encouragement to families to make their voices heard to affect policy change is also required.
For the long-term, more permanent affordable housing is essential. Long waiting lines for affordable housing programs such as Section 8 and the Rental Voucher Program indicate the necessity for increased investment of such programs. When housing becomes available there has to be a fair distribution of these resources. Further investment in homelessness prevention programs is also a necessity. Once a system is in place to immediately place families in stable housing situations, a true “Housing First” policy will exist.
Proposed Changes Ensure Stability for Families to Build Hierarchy of Needs  
The proposed policy has many components that will give homeless families the foundation they need to fulfill their hierarchy of needs from the ground up. By requiring language in EA shelter policy to include those at imminent risk of having to stay in a place not meant for human habitation, families no longer have to fear not having the basic needs of sleep and food. Safety needs are also met since there is no danger of living in dangerous situations. In order to ensure that the basic need of safety is met it is a must to keep access to EA shelters.
To help families achieve higher needs such as love and belonging, esteem, and self-actualization they must have the confidence that their living situation is not fleeting. Current efforts to prevent homelessness like Residential Assistance for Families in Transition (RAFT), is helpful but is only for the short term. With the proposed intervention, such programs would be expanded upon and be more long term. For those in the shelter system, a systematic way of fairly distributing available affordable housing resources is a must. Current policy does not distribute housing subsidies to those families who have been in the shelter system the longest or with those who may have disability needs (3). With the new proposed policy those in need of housing will get the resources they need in an organized fashion that will leave no room for doubt.  A greater sense of security will allow these families to start thinking beyond the day-to-day struggle to stay housed.  With the sense that things are proceeding orderly and everyone in the family is in a less hyper aroused state of stress.
Proposed Changes Eliminate Stigma by Promoting Advocacy
There are certain methods to combat stigma. One such method consists of creating a social movement to fight the negative stereotypes attached to a given stigma (12). Prevent families from feeling stigmatized by helping them to become advocates from themselves. One key to helping those in crisis is education. In such an overwhelming situation, families are not be privy to the resources available to them and what their rights are.  For instance, families applying for shelter may be reluctant to reveal all details of their housing situation. They feel that if it is known parent and child are sleeping in uninhabitable conditions (such as a car) they could risk losing their children and end up being denied shelter. Unfortunately, under current policy this omission of truth makes them ineligible for shelter. There are protections for families in such situations that would prevent child services from separating children from their parents (3). Therefore, education is required to make families aware of the policy to prevent this from happening.  Families that end up in health center clinics or emergency departments may be connected to advocates that can help them through the process. Still, there are many families that social workers and other advocates may not hear about. An expansion in homeless prevention programs can put advocates in contact with the people who need resources the most. 
Another component of building advocacy and bringing the issue of homelessness to the forefront is agenda setting. By framing the issue of homelessness appropriately, emphasizing the core value of independence, families can fight to have policy reformed. The voice of this issue should not solely be the experts who do the research. The voices of families experiencing homelessness are also needed. Personal narratives are vital to produce the emotional heft required to grab attention. There are countless stories of homeless families that should be heard to shape public perception. To have the public understand that no child should have to sleep on the street gain access to EA will help build support for action. As important as it is to hear their stories, it is also important the homeless not be portrayed in the media as victims or “other” people in our society as many media outlets do (15). Instead, the homeless should be expert sources to inform the public about the issues of homelessness in general. They deserve to be treated as citizens with valid opinions and solutions to the issue. Productively contributing to the debate of homeless policy is a source of empowerment that can eliminate the stigma homeless families may experience. 

Proposed Changes Reduce the Burden on the Healthcare System
Hospitals emergency departments can no longer serve as a place to house the homeless. Resources need to be focused on those truly needing emergency care. Providing shelter will help to ease the burden on healthcare services. While working to house the homeless in appropriate shelter, it is important not to forget healthcare needs. The homeless are sicker and have mortality rates higher than the general population (16).  Providing housing can serve as a solution of reducing illness. Dr. Bella Schanzer’s longitudinal study found that newly homeless persons struggle under the combined burdens of residential instability and significant levels of physical disease and mental illness, but many experience some improvements in their health status and access to care during their time in the homeless shelter system (17).  By providing housing stability, the basic health needs of the homeless can begin to improve. To achieve this goal will require commitment to meaningful collaboration between the medical community and the DHCD.
While Massachusetts’ commitment to providing housing, shelter, and emergency assistance to low-income families is commendable, recent policy change limiting the eligibility to emergency assistance has resulted in devastating consequences that influences families facing homelessness as well as the healthcare system. Shifting funds from the EA shelter to homelessness prevention does not help the situation. The current policy “pretends” there are less homeless people by letting less homeless people into emergency assistance shelters. Families stuck in this precarious and daunting system face emotional and physical stress. Many essential needs are left unmet which puts a strain on the homeless leaving them feeling stigmatized. Ultimately, to solve the housing crisis more affordable housing is required in Massachusetts along with reformed policy accounting for families facing homelessness. Those facing this crisis should be educated about their rights and become advocates for the issue. With a comprehensive reform of policy in place Massachusetts can begin to solve the crisis of family homelessness.
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