New research has indicated the extent to which cutting rates of homelessness would save lives by preventing drug-related deaths. The findings are further strong evidence, the authors say, for why juridictions should take action to reduce evictions and promote housing first policies.
The study was published in the February issue of the journal Health Affairs. The researchers examined federal Department of Housing and Urban Development (HUD) data between 2007-2017. They looked at change in rates of deaths involving different opioids, stimulants like meth and cocaine, benzodiazepines, anti-depressants and alcohol. They compared these data to local counts of unhoused residents all over the country, including people in different “stages” of homelessness—sheltered, unsheltered and those who are chronically unhoused.
Seeking to estimate what they identifed as “the causal impact of homelessness” on such deaths, the authors found “large effects,” and projected numbers for certain scenarios. For example, they estimated that if homelessness were decreased by 25 percent, close to 2,000 lives per year nationwide would be saved from opioid-involved overdose. In the same scenario, about 842 alcohol-poisoning deaths and 540 cocaine-involved deaths would also be averted.
“People die when they’re in isolation.”
The thrust of the research will come as little surprise to anyone familiar with harm reduction and homelessness. Being without a home, living on the streets or in public spaces, exacerbates risks of substance use in numerous ways. It means no bathroom, sink or toilet to maintain hygiene, increasing risks of bacterial and viral infection. It means having to inject, smoke or snort in outdoor or public areas, placing the emphasis on speed to avoid detection, rather than safety. It means worrying about your possessions being lost or stolen, which makes it harder to obtain, retain and use lifesaving supplies like sterile syringes and naloxone. And that’s not all.
“People die when they’re in isolation,” Donald H. Whitehead Jr., executive director of National Coalition for the Homeless, told Filter. For people experiencing an opioid-involved overdose, he continued, “if they’re in a house or with others, they can typically be saved by Narcan or another intervention. Because people have been pushed out due to criminalization practices, they’re often on their own.”
Among people experiencing homelessness, Whitehead added, substance use disorder or chaotic use frequently co-occurs with trauma and other mental health needs for which treatment and support are unavailable.
The researchers concluded that increasing protections for renters would be an effective way of reducing drug-related deaths.
A key element of the new study was researchers’ investigation of how eviction policies in different areas of the country affected a region’s homelessness rate. They concluded that increasing protections for renters would be an effective way of reducing drug-related deaths. In August 2021, the federal government suspended a moratorium on evictions put in place during the COVID-19 pandemic. Many cities have seen a corresponding rise in homelessness.
“We needed something that would [affect] homelessness but not directly affect the rate of accidental poisoning,” W. David Bradford, PhD, of the Department of Public Administration and Policy at the University of Georgia, and co-author of the study, told Filter of the evictions angle. “[W]e know from past research that housing policies prohibiting evictions in small claims court, or that protect tenants from landlord retaliation, these have been shown to reduce evictions, and we know if you reduce evictions you reduce homelessness.”
“We chose this [policy] aimed at the eviction world, but those laws aren’t aimed at managing substance use. That’s how we were able to isolate the effect we wanted and not get this reverse feedback.”
Nationwide, the number of unhoused individuals has increased dramatically in the last few years. According to a new report released by Harvard researchers, the rate of homelessness in January 2023 was up 12 percent on January 2022. That was the largest increase in homelessness, in a single year, on record—and up 48 percent since 2015.
Many factors have driven this—including a decades-long rise in housing costs around the country, the expiration of pandemic-era safety net programs like the evictions moratorium, and the impact of inflation on wallets and bank accounts post-pandemic.
Past research has also shown the acute risk of overdose faced by people experiencing homelessness. One 2022 study of over a large group of unhoused people in Boston between 2003-2018 showed that of over 7,100 people who died over that 15-year period, about one in four died of overdose—with deaths involving synthetic opioids like fentanyl, as well as those involving multiple substances, increasing dramatically.
Heightened mortality risks among unhoused people are not just related to overdose, of course, when homelessness is hugely detrimental to a person’s overall physical and mental health.
Other researchers have looked at mortality among unhoused people, and found a general risk of sudden death much higher than in the general population. Researchers at the University of California-San Francisco, for example, found unhoused people had a seven times greater risk of sudden cardiac death, and were more likely to die of gastrointestinal disorders and infections, as well as from overdose, compared to the general population. Another major impact on mortality is extremely high rates of cigarette smoking among unhoused populations, in part to relieve stress and boredom, which presents its own harm reduction need.
“When we provide the resources, housing and supportive services, the results from that are overwhelmingly successful.”
The new study does not tell us specifically about changing rates of drug-related deaths among unhoused people, but rather sets changing overall rates of those deaths against measures of homelessness.
“We don’t actually see an indicator in the death certificate for whether the person was homeless or not,” Dr. Bradford said. “So we don’t know what’s happening with regards to mortality in the homeless population … One thing I’d love to see is things like death certificates become more informative about telling us about situations that people were found in. Anything we can do to identify vulnerable populations, in datasets like the Vital Statistics, would help us study those populations more precisely and give better feedback to policy makers.”
The new research adds further scientific support for what should be very obvious: People who have homes and support for their needs have much better chances of survival and wellbeing.
“[When we] provide the resources, housing and supportive services, the results from that are overwhelmingly successful,” Whitehead said, adding that substance use “typically starts to go down” when people are provided with housing and support.
Bradford supports more cities and counties embracing the “housing first” model for giving people permanent and stable housing without a requirement of abstinence from drugs, while offering care for psychiatric and substance use needs. Research shows this keeps people housed longer, saves local governments money on hospitals and jails, and works better for people in vulnerable situations.
“As time goes on and we see more localities trying housing first policies, those seem promising to me because that’s a direct shot at homelessness,” Bradford said. “[They] just take someone off the street, don’t worry about fixing all their problems before you give them a house, give them a place to live, and then we can try to work on their problems. I would love in a few years for there to be harmonized data across these initiatives.”
Photograph (cropped) of an encampment in Fort Lauderdale, Florida, in 2018 by Tamanoeconomico via Wikimedia Commons/Creative Commons 4.0
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