Originally published by 2 Minute Medicine^® (view original article). Reused on AccessMedicine with permission.

1. 1 in 4 deaths of people experiencing homelessness in Boston, Massachusetts were attributable to drug overdose between the years 2003 and 2018.

2. Synthetic opioid and polysubstance abuse were lead causes of mortality in the more recent years of the study period.

Evidence Rating Level: 2 (Good)

Study Rundown:

Drug-related death has become an increasingly important cause of mortality in North America and disproportionately affects people experiencing homelessness. Despite the significance of this public health crisis, overdose deaths and opportunities for intervention in this population remain understudied. The present study sought to describe patterns of substance use amongst people experiencing homelessness in an urban American city and understand major drug-related contributors to mortality over a 16-year time period. A cohort of 60,092 adults experiencing homelessness in Boston was identified. The mean follow-up duration was 8.7 years and the mean age of the cohort at the time of study identification was 40.4 years. 7130 deaths occurred amongst this cohort between 2003 and 2018, of which 1727 (24.2%) were due to drug overdose. The age- and sex-standardized overdose mortality rate was 12 times higher amongst people experiencing homelessness compared to the Massachusetts general population. The most common drugs implicated in overdose deaths were opioids, followed by cocaine and benzodiazepines. Notably, the rate of opioid-related deaths increased over the study period, particularly for synthetic opioids which were involved in 96.1% of all opioid-related deaths in 2018 compared to 0% in 2004. This study by Fine et al unequivocally paints a picture of health disparities amongst the urban population in a large, American city. Drug related deaths were significantly higher amongst people experiencing homelessness compared to those in the general population. Patterns of drug use and mortality were also explored in this study, with opioids accounting for a significant proportion of deaths in later years of the study. Strengths of this study include the large size of the cohort and rigorous data collection. The retrospective nature of this work renders it susceptible to bias from confounding variables. Finally, limited accurate data about this population necessitates reliance on a number of assumptions which may reduce the validity of reported findings.

Click to read this study in JAMA Network Open

Click to read an accompanying editorial in JAMA Network Open

Relevant Reading: Sheltering risks: implementation of harm reduction in homeless shelters during an overdose emergency

In-Depth [retrospective cohort study]:

A retrospective cohort was derived from a database of client encounters at the Boston Health Care for the Homeless Program (BHCHP) between 2003 and 2018. Individuals in this program are eligible if they are unhoused at the time of registration. Data from the BHCHP or the Centers for Disease Control and Prevention were recorded through self-reporting or by observation. Mortality data were obtained through the state’s Department of Public Health death records using data linked from individuals identified through BHCHP data. The demographic breakdown of the 1727 drug-overdose deaths identified amongst the study cohort are as follows: 1271 (73.6%) were male, 456 were female (26.4%), 194 were Black (11.2%), 202 were Latinx (11.7%), and 1185 were White (68.6%). The age- and sex- standardized overdose-specific mortality rate amongst the study cohort was 278.9 per 100,000 person-years (95% confidence interval [CI] 266.1-292.3), and was 23.2 per 100,000 person-years (22.8-23.5) in the general population. 91.1% of overdose deaths involved opioids, 36.6% involved cocaine and 16.2% involved benzodiazepines. The rate of opioid-related deaths increased from 161.2 to 340.2 per 100,000 person-years between 2004 and 2018, respectively. The standardized drug-related mortality rate in individuals experiencing homelessness compared to the general population was highest amongst Asian or Pacific Islander individuals (44.3, 95% CI 18.0-92.2) and lowest amongst Black individuals (5.5, 95% CI 4.8-6.3).

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