A large-scale study of individuals experiencing homelessness in Boston over the past two decades shows a worrying increase in overdose deaths due to both synthetic opioids and the use of multiple substances.

The study, which was led by Danielle Fine, MD, MSc, and Travis Baggett, MD, MPH, highlights the need to improve access to evidence-based treatments for opioid use disorder (OUD) and overdose protection services in this highly vulnerable population.

Here are five things to know about the study, which was recently published in JAMA Network Open.

The researchers analyzed the health records of 60,097 individuals aged 18 and over who received treatment from the Boston Health Care for the Homeless Program (BHCHP) from 2003 to 2018.

Within that group, 7,130 individuals died during the study period, with one in four deaths (24.2%) due to drug overdose. 68.6% of the overdose deaths occurred in Whites, 11.2% in Black and 11.7% in Latinx individuals.

Opioids were implicated in 91% of the overdose deaths, and deaths from synthetic opioids such as fentanyl increased by more than 1,400% between 2013 and 2018. By 2018, synthetic opioids were involved in 96% of all opioid-related deaths. Deaths from polysubstance use (the use of opioids and another substance such as cocaine) accounted for two-thirds of drug overdose deaths in 2018.

The overdose death rate in the study group was 12 times higher than the general population of Massachusetts during that time frame. Consistent with national trends, the researchers found that since 2010, overdose death rates among Black and Latinx individuals have been rising more rapidly than the rates among White individuals.

Overdose rates in the study group were consistently higher across all races and ethnicities, but the largest disparities occurred within Whites. This is likely due to the differing factors that contribute to homelessness, the researchers say.

Research has shown that white individuals who are homeless are more likely to have mental health and substance use disorder problems. The path towards homelessness for Black and Latinx individuals is more often related to poor economic opportunities, housing segregation and higher rates of incarceration.

The team’s findings highlight the need to increase access to evidence-based OUD treatment and overdose protection strategies such as supervised injection facilities, fentanyl testing strips and naloxone.

Delivering treatment services directly to the homeless population by using mobile vans or providing services at homeless shelters could help to engage more individuals in care, the researchers say.

“When people are treated for opioid use disorder, we can really save lives,” says Fine, the lead author of the study. “A lot of it is just meeting people where they are to get treatment to as many people as possible, because the more people we treat, the more lives we can save.”

The team’s findings also highlight the need to increase access to affordable housing, says Fine.

“Oftentimes, people think that housing and substance use is unidirectional—there’s a flow in one direction,” she explains. “But some people experiencing homelessness [for other reasons] will start using substances because they feel like they’re in a situation they can’t get out of.”

From a research standpoint, the next step will be to learn more about polysubstance use and to identify the best interventions to help individuals who are using multiple substances at the same time.

“In the cases where this use is intentional, we need to provide treatment,” Fine says. “Where it’s not intentional, we need to make sure we’re providing education to people to let them know that opioids are probably going to be contaminating their drug supply.”

Drs. Fine and Baggett are physician-investigators in the Division of General Internal Medicine at Massachusetts General Hospital. Baggett is also the director of research at the Boston Health Care for the Homeless Program (BHCHP) and an MGH Research Scholar 2021-2026.

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