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Drug Overdose Is Leading Cause of Death for Homeless People in Boston

The mortality rate among homeless people in Boston has remained steady over the past 2 decades, but drug overdose has overtaken HIV as a leading cause of death, researchers reported in the January 14, 2013, advance edition of JAMA Internal Medicine.

Travis Baggett from Massachusetts General Hospital and colleagues looked at all-cause and cause-specific mortality rates in a cohort of 28,033 adults who received care through the Boston Health Care for the Homeless Program (BHCHP), which serves more than 11,000 homeless men, women, and children annually at 2 major teaching hospitals and more than 80 shelters and other sites. 

This analysis looked at mortality rates and causes of death between 2003 and 2008, comparing them to corresponding rates seen during 1988-1993, at the height of the AIDS epidemic.

Results

• A total of 1302 deaths among BHCHP participants occurred during 90,450 person-years of observation.
• The most common causes of death were:

o   Drug overdose: 219 deaths;

o   Cancer: 206 deaths;

o   Heart disease: 203 deaths.

• Overall mortality rates were not significantly different during 2003-2008 compared with 1988-1993.
• However, causes of death shifted from the earlier period, in which the leading causes were homicide for BHCHP patients age 18-24 years, HIV for those 25 to 44, and heart disease and cancer for those 45 to 64. 
• Drug overdose accounted for 17% of all homeless deaths during the recent period (and one-third of deaths among adults younger than 45 years), compared with 6% during 1988-1993.
• 81% of overdose deaths involved opioids such as heroin and prescription pain medications.
• Health issues associated with substance abuse -- including alcoholism-associated heart disease, pneumonia, and drug/alcohol withdrawal -- accounted for 8% of deaths.
• Conversely, 6% of deaths during 2003-2008 were due to HIV disease compared with 18% during 1988-1993, as the later period benefitted from decreased HIV incidence and the advent of effective combination antiretroviral therapy starting in 1996.
• The decline in HIV deaths was offset by a 3-fold increase in deaths due to drug overdose and a 2-fold increase in other causes of death related to substance use.
• Mortality rates were higher among white BHCHP participants compared with other racial/ethnic groups.
• Mortality disparities between homeless adults and the Massachusetts general population were most pronounced among younger people:

o   25-44 years: 9.0-fold higher mortality;

o   45-64 years: 4.5-fold higher rate of death.

Based on these findings, the researchers concluded, "The all-cause mortality rate among homeless adults in Boston remains high and unchanged since 1988 to 1993 despite a major interim expansion in clinical services."

"Drug overdose has replaced HIV as the emerging epidemic," they continued. "Interventions to reduce mortality in this population should include behavioral health integration into primary medical care, public health initiatives to prevent and reverse drug overdose, and social policy measures to end homelessness."

A recent study found that distributing the opiate antagonist naloxone (Narcan) is a cost-effective way to reduce overdose deaths.

"Our findings are an unfortunate reminder of the high mortality rate of homeless people and a clarion call for the need to address the epidemic of drug overdose deaths in this vulnerable population," Baggett said in a press release issued by Massachusetts General. "Our results highlight the dire need to expand addiction and mental health services and to better integrate them into primary care systems serving homeless people...Making a major impact on mortality for these patients will also require addressing the social factors that contribute to homelessness in the first place." 

In response to the study, BHCHP and the Boston Public Health Commission are leading a citywide effort to address the high number of overdose deaths from a medical and policy perspective, the release noted.

1/29/13

Reference

TP Baggett, SW Hwang, JJ O'Connell, et al. Mortality Among Homeless Adults in Boston Shifts in Causes of Death Over a 15-Year Period. JAMA Internal Medicine. January 14, 2013 (Epub ahead of print); February 11, 2013 (Issue in print).

Other Source

Massachusetts General Hospital. Drug Overdose Now the Leading Cause of Death Among Homeless Adults in Boston. Press release. January 14, 2013.