Healthcare Mistrust, Stigma, and Reported Influences on Substance Use among Adults Experiencing Homelessness in Downtown Manhattan: A Convergent Mixed-Methods Pilot Study

In the crowded streets of a major city, the gap between a person in crisis and the help they need is often not a matter of distance, but of trust. For adults experiencing homelessness, the path to healthcare is rarely a straight line. It is shaped by whether they feel safe, whether they believe a doctor will listen without judgment, and whether the system offers solutions that fit their immediate reality, such as a place to sleep or a way to stay clean. While official records often count the tragic losses in this population, they rarely capture the voices of those who survive. These survivors carry a unique understanding of what works, what fails, and why so many remain disconnected from the care that could save them. When researchers look beyond the statistics of death and overdose, they find a complex landscape of barriers where a lack of housing, a history of trauma, and the fear of being treated as a criminal can be just as deadly as the substances themselves.

A recent pilot study set out to listen to these voices directly, walking the streets of Downtown Manhattan to understand the lived experience of unhoused adults. Between July 7 and July 24, 2024, a team of researchers approached eighteen adults along the busy 14th Street corridor and around Union Square Park. The goal was not to conduct a formal medical exam or to offer a quick fix, but to have a conversation. The interviewer, a medical student, spoke with each person for twenty to thirty minutes, asking about their history, their daily struggles, and their views on the healthcare system. To keep the interaction as natural and unintrusive as possible, no audio recorders were used. Instead, the interviewer wrote down notes by hand, capturing the stories and concerns as they were shared. This approach allowed the participants to speak freely in the places where they already spent their time, creating a space where they could define their own needs.

The group of eighteen people included fourteen men and four women, with an average age of forty-five. Most had been without stable housing for a long time; the median duration of their homelessness was over two years, though for some, it had stretched on for nearly eight years. When asked about their access to healthcare and addiction support, the group gave a mixed but generally low rating. On a scale where one represents very poor access and five represents excellent access, the average score was just under three. This suggests that while services might physically exist nearby, they do not feel accessible or helpful to the people who need them most. The researchers noted that Black participants, who made up the majority of the group, reported slightly lower levels of access than White or Hispanic participants, though the small number of people in each group meant these differences could not be confirmed as a statistical rule.

The stories behind these numbers revealed a deep sense of systemic neglect. Many participants described a world where services are visible but insufficient. They spoke of clinics that are slow to respond, shelters that feel unsafe, and rules that force them to choose between their partners, their pets, or their safety. One person summarized the situation by saying the services keep them alive but do not get them off the street. This feeling of being kept in a state of survival rather than being helped to rebuild a life was a recurring theme. Trust in institutions was often broken by specific negative experiences, such as being turned away for treatment, having follow-up care cut off, or being accused of seeking drugs rather than seeking help. These encounters created a barrier where physical proximity to a doctor did not translate into a feeling of safety or care.

When the researchers asked about what influenced the participants' use of substances, the answers pointed toward deep personal histories rather than simple choices. More than half of those who spoke on the topic described social or interpersonal factors, such as family norms or peer pressure. Nearly half mentioned trauma or difficult early-life experiences, including abuse or the loss of loved ones. Only a small number cited a specific medical event as the starting point. The study did not claim to prove that these factors caused the substance use, but the participants themselves identified these connections as central to their stories. This highlights that for many, substance use is intertwined with a history of pain and a lack of support, rather than being an isolated behavior.

A significant finding emerged when looking at the history of overdoses. Seven of the eighteen participants had survived an overdose in their lifetime. Among those who had survived an overdose, more than half spontaneously mentioned mental health or addiction as a current daily challenge. In contrast, only one person without a history of overdose brought up these issues unprompted. While the study was too small to declare this a definitive rule, the difference was sharp enough to suggest that those who have survived an overdose are acutely aware of their ongoing mental health needs. This finding points to a critical opportunity: survivors of overdose may be a key group to reach with targeted mental health and addiction support, as they are already identifying these struggles as central to their lives.

Despite the challenges, the participants were clear about what they needed most. The most frequently requested resource was housing, followed closely by financial assistance, employment support, and healthcare. The desire for housing was not just about having a roof; it was described as the foundation for everything else. Without a stable place to live, it is difficult to maintain hygiene, keep a job, or even access other services that require a mailing address. Participants explained that housing instability affects their safety, their psychological well-being, and their ability to stay connected with partners or family. The study concluded that effective help must go beyond medical treatment to include practical navigation of housing and basic needs.

The insights from this small group of eighteen people have already begun to shape real-world action. The findings informed the creation of a new nonprofit organization and a mobile application designed to help unhoused individuals navigate community resources. This tool, which offers information in both English and Spanish, aims to bridge the gap between people and the services they need, from harm reduction to housing support. While the application itself was not tested in this study, the research provided the blueprint for its development, ensuring it addresses the specific barriers of mistrust and complexity that the participants described. The study serves as a reminder that to solve the crisis of homelessness and overdose, we must first listen to the people living through it, understanding that their priorities—safety, dignity, and a place to call home—are the very keys to their recovery.