January 18, 2013
NIDA Director, Dr. Nora D. Volkow

Homelessness is a persistent problem—nearly 690,000 people are homeless on a given night in America—and it takes a terrible toll in sickness and mortality. The leading cause of death among homeless Americans used to be HIV, but that has been replaced by a new epidemic: drug overdose. A new study to appear next month in JAMA Internal Medicine found that overdoses—most of them involving opioids—are now the biggest killer among homeless people in the Boston area.

Drug overdoses accounted for almost 17 percent of the deaths in a cohort of over 28,000 current or former homeless adults studied from 2003 to 2008. Of those overdose deaths, 81 percent involved opioids. Cancer and heart disease were the next biggest killers (at around 16 percent each); HIV =accounted for just under 6 percent. (Age made a difference: For those between 25 and 44, drug overdose accounted for over a third of all deaths, whereas heart disease and cancer were leading causes of mortality for those over 45.) The new findings are in stark contrast to those from an earlier study examining mortality among Boston’s homeless between 1989 and 1993, when relative rates for HIV and overdose death were almost exactly the opposite—with overdose accounting for 6 percent of the deaths in that cohort and AIDS accounting for 18 percent. Importantly, mortality from all causes did not differ between the two studies. The reductions in deaths due to HIV over the 15 years separating the studies were completely offset by increases in deaths due to drug abuse as well as other mental health problems like suicide.

photo of homeless person alone in a dirty tunnel

In the general population, it is prescription drugs, particularly opioid painkillers, that now are the main cause of overdose death, outnumbering deaths from all other drugs (including heroin) combined. Of the opioids contributing to overdoses in the Boston study, the bulk were indeed painkillers and other non-heroin narcotics.

The toll of substance abuse among homeless people goes beyond fatal overdoses. Other deaths caused by substance use disorders, especially alcoholism, accounted for nearly 8 percent of the mortality in the new study—a two-fold increase over the earlier study. And looking deeper into the statistics, it is clear that addiction plays an even wider role in the high mortality of homeless adults: The high number of heart disease deaths and fact that most cancer deaths were from cancers attributable to smoking (e.g., lung, trachea) reflect the high rate of nicotine addiction among homeless adults, 73 percent of whom smoke (more than three times the rate for the general population).

Homeless people suffer disproportionately from all health problems, and drug abuse and addiction are no exceptions. Despite improvements in healthcare services for homeless people in the Boston area in the decade and a half between the two studies (including improvement of care and services for those with HIV), increasing deaths due to drugs and alcohol countered the other health gains. As the authors of the latest study note, this new epidemic must be addressed by expanding addiction and mental health services to homeless people, as well as upping our efforts to prevent prescription drug abuse and diversion both among homeless people (who have high rates of chronic pain and addiction) and more generally.

Increasing the availability of treatments such as buprenorphine is crucial, as is developing standardized protocols for pain management and enhancing physician education. (To that end, NIDA, partnering with other NIH ICs, is actively working to educate physicians about pain management through initiatives like the Centers of Excellence in Pain Education and Web-based screening tools to help doctors detect prescription and other drug abuse in their patients.) Indeed, any measures to address substance use disorders in our society, such as new treatments and prevention approaches, will ultimately help address the tragic problem of homelessness too, as many homeless people cite drug or alcohol problems as factors that led to their becoming homeless in the first place.