The rise in U.S. opioid overdose deaths has not spared people experiencing homelessness. In fact, this population is at increased risk of fatal overdose and opioid-related hospital admission compared to people who use drugs who have stable housing. We know that broader neighborhood characteristics, such as the location of needle exchanges, can affect how drugs are used among people experiencing homelessness; but what about smaller-scale aspects of the physical and social environment that may influence where and how people experiencing homelessness use drugs?

In a new study published in the International Journal of Drug Policy, we examine how neighborhood features influence where people experiencing homelessness might use drugs and increase the risk of death from opioid overdose. Using Google Street View, we remotely visited every block where a fatal opioid overdose happened in New York City from 2017 to 2019. We found that 55.9% of fatal overdoses among people experiencing homelessness occurred in supportive housing or shelters, and 15.5% occurred in public spaces (e.g., parks, public transit). When we accounted for overdoses in shelters or supportive housing, we found that construction, graffiti, traffic calming features, and neighborhood poverty level were features linked with overdose deaths. In terms of the social environment, fatal overdoses among people experiencing homelessness were more common on blocks where adults loitered.

Construction Scaffolding Associated with Overdoses

Construction on a block was associated with a 38% increase in odds of overdose fatality among people experiencing homelessness, controlling for other street and neighborhood characteristics. Construction in New York City has strict scaffolding requirements. These sidewalk sheds—tunnel-like structures made from wood and steel that cover walkways and catch debris—are ubiquitous in New York City, covering hundreds of miles of the city. For people experiencing homelessness who use drugs, scaffolding may provide a private space to protect from police harassment and be public enough to get help in case of an overdose. While the popular press has covered homeless encampments under scaffolding for years, to our knowledge this is the first peer-reviewed study to discuss scaffolding as a space for people without housing to use drugs.  Our results suggest that streets with scaffolding may be possible locations for targeting street outreach and harm reduction.

Improve Harm Reduction Among People Experiencing Homelessness

First, harm reduction and addiction treatment services should be available to support people experiencing homelessness who use drugs in shelters and supportive housing. While all staff in New York City shelters are trained to administer naloxone, shelters are not supervised consumption sites and do not offer comprehensive harm reduction or mental health services. Naloxone training alone is not enough to prevent fatal overdoses in these spaces. In addition, we should target outreach to blocks with specific features (e.g., scaffolding), and we also need policy-level interventions to address neighborhood processes that manifest on city streets (e.g., loitering).

This research is particularly relevant considering the popularity of street sweeps to address homeless encampments. Street sweeps cause disruptions to harm reduction and outreach for people experiencing homelessness, including loss of naloxone, sterile injection equipment, and medications. Descriptions of street block features located where people experiencing homelessness use drugs may be useful for proactively targeting harm reduction to blocks where these citizens congregate after a sweep.

The study, “City Streetscapes and Neighborhood Characteristics of Fatal Opioid Overdoses Among People Experiencing Homelessness Who Use Drugs in New York City, 2017–2019,” was published in the International Journal of Drug Policy in December 2022. Authors include Elizabeth D. Nesoff, Douglas J.Wiebe, and Silvia S. Martin.


Elizabeth Nesoff

Elizabeth D. Nesoff, PhD, MPH

Assistant Professor, Biostatistics, Epidemiology and Informatics, Perelman School of Medicine

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