Preventing Overdose in Supportive Housing: Stepped Wedge Randomized Controlled Trial of a Multi-Sector, Upstream Intervention

Homelessness and housing instability are strongly linked with overdose risk. Permanent supportive housing (PSH)—subsidized housing paired with support services—is a key part of the national strategy to end homelessness. PSH tenants face high overdose risk due to a confluence of factors. Despite this risk, little past research has examined overdose prevention in PSH or even as related to housing more generally. We propose a multi-sector, community-partnered, stepped wedge randomized controlled trial (RCT) to evaluate the impact of a technical assistance (TA) intervention designed to support PSH agencies in sustainably implementing evidence-based practices to reduce tenant overdose and improve tenant health more broadly. The intervention will be delivered to PSH agencies in New Jersey and New York by a collaborative multi-sector team led by community organizations with national footprints. The intervention addresses not only individual tenant behavioral risks but also acts at the larger agency and building levels. The study includes a UG3 planning phase and a UH3 trial phase, with milestones defined for each phase. In UG3 Aim 1, we will conduct focus groups with PSH leaders, staff, and tenants to refine an overdose prevention TA package (the intervention) that is feasible, acceptable, and appropriate for varied PSH types across New Jersey and New York. In UG3 Aim 2, we will conduct preparatory activities for the RCT, including site selection, data agreement execution, data collection instrument and analysis plan finalization, and IRB approval. In UH3 Aim 1, we will conduct a stepped wedge RCT to examine the impact of the TA intervention on PSH agency implementation of overdose prevention practices and downstream tenant overdose, substance use, and other health-related outcomes. Outcomes will be assessed using surveys, administrative Medicaid and PSH data, and PSH agency records. In UH3 Aim 2, we will identify implementation successes and challenges, and explore pathways between the intervention and tenant overdose risk and related health outcomes, using qualitative interviews with PSH tenants and staff. In UH3 Aim 3, we will integrate the results of UH3 Aims 1–2 using a convergent mixed methods design, and disseminate findings to ensure translation of the research into practice and policy locally and nationally. It is expected that findings from this research will be immediately actionable and will also be broadly applicable to other housing settings and homeless shelters. Ultimately, we aim to reduce overdose and improve related health outcomes by focusing on a critical yet understudied aspect of overdose prevention with national relevance. This study is part of the NIH’s Helping to End Addiction Long-term (HEAL) initiative to speed scientific solutions for the overdose epidemic, including opioid and stimulant use disorders. The NIH HEAL Initiative bolsters research across NIH to address the national opioid public health crisis and improve treatment for opioid misuse and addiction.