The opioid crisis and the homelessness epidemic in the U.S. are not just overlapping issues—they fuel each other in a relentless cycle, deepening vulnerability and exposing the failures of government-only approaches to social services. Traditional policies have largely failed to address the connection between substance use and housing instability. They often focus on punitive measures or strict bureaucratic requirements rather than on solutions that help people find shelter and also offer the stability, support, and medical care needed for long-term recovery and successful reintegration into society.
Beyond the failures of addiction policy, housing scarcity—driven by excessive government regulation—has made it nearly impossible for many to escape homelessness. Restrictive zoning laws, costly permitting requirements, and government-imposed limits on housing supply have driven up rent prices, placing housing increasingly out of the financial reach of many Americans.
Homelessness and substance use disorders (SUDs) are deeply intertwined, with problematic use of opioids, stimulants, and alcohol disproportionately affecting unhoused populations. Those who are homeless face a significantly higher risk of fatal overdose. Studies show that a 10% rise in homelessness is correlated with a 3.2% increase in opioid poisonings in metropolitan areas.
Government mismanagement of housing and development policies, marked by excessive zoning laws, building restrictions, and ineffective public housing programs, has made it increasingly hard for the vulnerable to find shelter. Secure housing, healthcare access, and harm reduction services are essential for reducing the risks of overdose and infectious diseases while enhancing the chance for a healthier life. When the challenges of life on the street are compounded by addiction, recovery becomes exponentially more difficult.
Integrating harm reduction strategies with housing first models may create a sustainable path forward that is both compassionate and effective in addressing this socio-medical crisis. However, for housing first to succeed, cities must remove the artificial barriers that prevent housing construction in the first place.
The failure of shelters and short-term solutions
Rather than serving as a refuge, many traditional government-funded shelters impose rigid rules and entry requirements that create barriers to access, particularly for those struggling with addiction. Strict sobriety requirements, curfews, and limitations on personal belongings deter many from seeking help, leaving them in unsafe conditions on the streets. While these policies are often considered safety measures, they fail to account for the realities of addiction and frequently push individuals into encampments as a last resort. When these encampments are forcibly cleared, people often lose critical medications, leading to severe health crises such as untreated diabetes, withdrawal-related complications, and increased overdose risks.
But as encampments grow, cities respond by treating homelessness as a public nuisance rather than a housing crisis, resorting to encampment sweeps to make homelessness less visible. While encampments can create public health and safety concerns—blocking sidewalks, occupying parks, and straining sanitation services—sweeps do not address the root of the problem. Instead, they create a cycle of displacement without providing stable alternatives. The underlying issue remains: Without adequate housing options, encampments will persist. Addressing the housing shortage is the only long-term solution to both homelessness and the challenges encampments pose to public spaces.
Housing first: A proven yet underused solution
Housing first takes a different approach to providing shelter by removing abstinence-based conditions and providing immediate, stable housing. Unlike traditional shelters, housing first prioritizes rapid placement into permanent housing without preconditions, recognizing that stability is a prerequisite for long-term recovery. This model is grounded in the idea that providing housing first makes it easier for individuals to engage in substance use treatment, mental health care, and employment services, rather than expecting them to achieve stability while living on the streets. While some worry that lowering barriers to entry could lead to disruptive or unsafe situations, housing first programs approach these challenges by incorporating case management and support services to help residents maintain housing stability and address behavioral issues as needed.
Evidence supports the effectiveness of this approach. In Boston, a harm reduction-focused transitional housing program successfully combined low-barrier housing with on-site substance use disorder (SUD) treatment. Unlike traditional shelters, this program did not require sobriety, yet 100% of participants engaged in case management, 49% received SUD treatment, and 25% transitioned to permanent housing within a year. This 25% transition rate is particularly impressive when compared to a systematic review of housing first programs, which found that only 27% of participants in traditional abstinence-based programs achieved stable housing within six months. It is particularly noteworthy that a single program achieved 93% of the combined outcomes of multiple programs.
The Boston program also included a short-stay stabilization unit, allowing individuals experiencing withdrawal or medical complications to receive immediate care without needing to enter a hospital. Over the first year of the program, the number of opioid overdoses requiring emergency intervention decreased by 40% due to on-site care, and treatment retention significantly outpaced that of abstinence-based programs.
Similarly, a transitional housing program in Hawaii, where 74% of the homeless population had methamphetamine use disorder and 12% had opioid use disorder, demonstrated that integrating housing with on-site healthcare led to a 62% increase in mental health treatment engagement and a measurable decline in emergency room visits and overdoses.
However, the success of housing first approaches depends on proper implementation and support. Critics often point to Oregon’s Measure 110 as an example of failed drug policy reform. While Measure 110 decriminalized possession of small amounts of drugs, the treatment and housing programs central to its success were never fully implemented as planned. This delay created a situation where drug decriminalization occurred without the necessary support structures in place, leading to misleading perceptions about the policy’s effectiveness. Housing first is not a standalone solution but part of a comprehensive approach requiring proper integration with other social services.
Why housing first can’t succeed without zoning reform
These findings reinforce what harm reduction advocates have long argued: Housing must be a starting point, not a reward for sobriety. Housing first programs follow this same principle, providing immediate housing with low barriers to entry while offering voluntary wraparound services.
Despite its proven effectiveness, housing first programs cannot succeed at scale without an adequate housing supply. Restrictive zoning laws, excessive permitting costs, and government-imposed density limits make it nearly impossible to construct affordable housing in the areas where it is needed most. Local governments wield significant power in shaping housing accessibility through land use policies, determining what can be built and where. Historically, these policies were often designed to exclude low-income individuals and people of color, with tools like single-family zoning used to block the construction of apartments and other affordable housing options.
Today, restrictive zoning codes continue to limit the development of multifamily housing, including housing designated for those experiencing homelessness. Beyond single-family zoning, parking minimums, parcel size regulations, setback mandates, and other requirements further drive up construction costs, making housing and essential support services—such as mental health care and addiction treatment—more difficult to establish. The result is a landscape where communities with strict zoning policies see higher housing costs, more significant barriers to affordable development, and deeper racial and economic segregation.
Houston, Texas, provides a compelling case study of how a combination of housing first policies and a more flexible approach to land use can create effective solutions to homelessness. Houston is unique among major U.S. cities because it has never implemented formal zoning laws. This absence of restrictive zoning has allowed for a more flexible approach to housing development. As a result, it is easier to construct various housing types, including affordable units and transitional housing, which has kept home prices and rents reasonable and made housing homeless individuals easier.
At the same time, Houston successfully implemented a housing first strategy in 2011, prioritizing getting people into stable housing without preconditions like sobriety or employment. The success of this approach has been bolstered by the city’s ability to build housing more freely. Together, these policies have contributed to a 68% reduction in chronic homelessness since 2011—demonstrating that reducing barriers to housing construction and housing access can create a more effective and scalable solution to homelessness.
Houston’s success is a direct result of its flexible zoning laws and lower housing costs, which make it dramatically cheaper to place individuals in stable housing than in cities like San Francisco. Unlike California’s restrictive zoning policies, which drive up housing costs and limit the supply of low-cost units, Houston’s flexible land-use regulations have fostered a greater availability of naturally affordable housing.
This difference is reflected in the cost of implementing housing first policies: Houston’s homeless service providers report that the total cost of housing and supportive services for one individual is between $17,000 and $19,000 per year, with only $12,000 going toward rent. In contrast, San Francisco spends between $40,000 and $47,000 per person annually, with housing alone costing as much as $35,000—nearly three times Houston’s cost. The reason is simple: San Francisco’s high rents, driven by restrictive zoning and artificial housing scarcity, make it nearly impossible to scale housing first programs efficiently. On the other hand, Houston has been able to house over 25,000 individuals, partly because its zoning laws encourage more housing development, ensuring an ongoing supply of affordable units.
What policymakers must do to end this crisis
To effectively address the intersection of drug policy and housing instability, the following recommendations are crucial:
Drug policy recommendations
Invest in harm reduction-focused housing
Shelters and supportive housing programs should integrate harm reduction services, yet funding for low-barrier housing remains severely lacking due to systemic barriers. Many affordable housing subsidy programs are structured around developer-focused incentives that overlook harm reduction priorities, and Section 8 policies often lack the flexibility needed to support harm reduction services. Additionally, many nonprofit organizations face constraints such as insufficient funding, understaffing, and a shortage of available beds or housing units. Greater flexibility in existing funding structures would significantly expand access to vital services. Programs can be more effectively resourced by combining public dollars with charitable and private funding and leveraging local community organizations. Additionally, reallocating resources toward housing first models would further enhance service delivery. Research shows that harm reduction-informed housing leads to longer stays, greater health improvements, and higher rates of stable housing retention—outcomes that punitive models consistently fail to achieve.
Eliminate abstinence-based barriers to housing
Sobriety requirements exclude the very people most in need of housing stability, forcing many into unsafe encampments or public spaces. Homeless program policies should be reformed to ensure housing eligibility is not contingent on abstinence from drug use. Housing first models—which provide unconditional housing alongside voluntary treatment services—have higher retention rates, better long-term health outcomes, and lower overall public costs than abstinence-based programs. The idea is to help them get sober, not just demand that they do so on their own before providing help. Federal and local governments should incentivize the expansion of housing first initiatives that integrate harm reduction and medical care.
Expand access to medication for opioid use disorder (MOUD)
Despite being some of the only treatment methods for opioid use disorder (OUD) currently permitted by the FDA, access to buprenorphine, naltrexone, and methadone remains severely restricted for unhoused individuals. Shelters and housing programs should expand low-barrier MOUD access, removing unnecessary requirements that delay or deny treatment. Programs that co-locate housing with MOUD services have been shown to reduce overdoses, improve treatment retention, and support long-term recovery.
Housing policy recommendations
Eliminate zoning laws that restrict housing supply
Restrictive zoning laws have artificially constrained housing supply, driving up costs and worsening homelessness. Cities should phase out many single-family zoning restrictions, which prevent the construction of multifamily housing, and remove excessive lot size mandates, height restrictions, and parking minimums that inflate construction costs. Updating these outdated land-use policies will create a wider variety of housing options, including smaller-scale infill projects, mixed-use developments, and affordable multi-family housing.
Streamline permitting and approval processes
Burdensome permitting and approval processes lead to delays and increased costs, discouraging private investment in affordable housing. We can significantly reduce bureaucratic obstacles by implementing by-right approvals for housing projects that comply with local zoning and safety standards rather than requiring discretionary approvals. Lowering excessive impact fees and regulatory costs for developers building affordable housing will further encourage private sector participation in addressing this crisis.
Expand adaptive reuse of existing buildings
Transforming vacant commercial spaces, underused office buildings, and hotels is a cost-effective way to expand housing options for individuals experiencing homelessness. However, zoning regulations and building code restrictions often prevent these conversions. State and local governments should ease regulatory barriers that hinder adaptive reuse while maintaining basic habitability standards. Converting existing structures into transitional and permanent housing provides a faster, lower-cost alternative to new construction.
Empower community-driven housing solutions
Government agencies should remove legal barriers preventing churches, nonprofits, and private property owners from developing transitional housing, tiny home communities, and other alternative solutions tailored to local needs. Rather than imposing top-down mandates, policymakers should support public-private partnerships that enable flexible, community-led approaches to housing instability.
Housing first works—if we let it
The link between homelessness and addiction is undeniable, yet policymakers continue to treat them as separate crises. The failure of traditional approaches—rigid shelter policies, punitive encampment sweeps, and abstinence-based housing—has only worsened conditions for those most vulnerable. Housing first policies have already proven their ability to break this cycle, but even the best programs cannot succeed at scale without the necessary housing supply.
The reality is simple: We must build more housing to reduce homelessness. Houston’s success shows that when barriers to housing development are lifted, housing first can thrive—housing more people at a fraction of the cost compared to cities with restrictive policies like San Francisco. Housing first works. The only thing standing in its way is bad policy.