Population-Level Health Effects of Involuntary Displacement of People Experiencing Unsheltered Homelessness Who Inject Drugs in US Cities
Joshua A. Barocas, Samantha K. Nall, Sarah Axelrath, Courtney Pladsen, Alaina Boyer, Alex H. Kral, Ashley A. Meehan, Alexandra Savinkina, David Peery, Michael Bien, Christine Agnew-Brune, Jesse L. Goldshear, Joey Chiang, Benjamin P. Linas, Gregg Gonsalves, Ricky N. Bluthenthal, Emily Mosites, NHBS Study Group, Pascale Wortley, Jeff Todd, David W. Melton, Colin Flynn, Danielle German, R. Monina Klevens, Rose Doherty, Conall O’Cleirigh, Antonio Moreno Jiménez, Thomas Clyde, Jonathon Poe, Margaret Vaaler, Jie Deng, Alia Al‐Tayyib, Danielle Shodell, Emily Higgins, Vivian Griffin, Corrine Sanger, Salma Khuwaja, Zaida Lopez, Paige Padgett, Ekow Kwa Sey, Yingbo Ma, Hugo Santacruz, Meredith Brantley, Christopher K. Mathews, Jack Marr, Emma C. Spencer, Willie Nixon, David W. Forrest, Bridget Anderson, Ashley Tate, Meaghan Abrego, William T. Robinson, Narquis Barak, Jeremy Beckford, Sarah Braunstein, Alexis V. Rivera, Sidney Carrillo, Abdel R. Ibrahim, Afework Wogayehu, Luis Moraga, Kathleen A. Brady, Jennifer Shinefeld, Chrysanthus Nnumolu, Timothy W. Menza, E. Roberto Orellana, Amisha Bhattari, Anna M. Flynn, Onika Chambers, Marisa Ramos, Will McFarland, Jessica Lin, Desmond Miller, Sandra Miranda De León, Yadira Rolón-Colón, Maria P. Martinez, Tom Jaenicke, Saral Glick, Jennifer Kienzle, Brandie Smith, Toyah Reid, Jenevieve Opoku, Irene Kuo, Monica Adams, Amy R. Baugher, Dita Broz, Janet Burnett, Susan M. Chambers, Johanna Chapin-Bardales, Paul Denning, Teresa Finlayson, Senad Handanagić, Terence Hickey, Dafna Kanny, Kathryn Lee, Rashunda Lewis, Elana Morris, Evelyn Olansky, Taylor Robbins, Catlainn Sionéan, Amanda L. Smith
Abstract
Importance: At least 500 000 people in the US experience homelessness nightly. More than 30% of people experiencing homelessness also have a substance use disorder. Involuntary displacement is a common practice in responding to unsheltered people experiencing homelessness. Understanding the health implications of displacement (eg, "sweeps," "clearings," "cleanups") is important, especially as they relate to key substance use disorder outcomes. Objective: To estimate the long-term health effects of involuntary displacement of people experiencing homelessness who inject drugs in 23 US cities. Design, Setting, and Participants: A closed cohort microsimulation model that simulates the natural history of injection drug use and health outcomes among people experiencing homelessness who inject drugs in 23 US cities. The model was populated with city-level data from the Centers for Disease Control and Prevention's National HIV Behavioral Surveillance system and published data to make representative cohorts of people experiencing homelessness who inject drugs in those cities. Main Outcomes and Measures: Projected outcomes included overdose mortality, serious injection-related infections and mortality related to serious injection-related infections, hospitalizations, initiations of medications for opioid use disorder, and life-years lived over a 10-year period for 2 scenarios: "no displacement" and "continual involuntary displacement." The population-attributable fraction of continual displacement to mortality was estimated among this population. Results: Models estimated between 974 and 2175 additional overdose deaths per 10 000 people experiencing homelessness at 10 years in scenarios in which people experiencing homelessness who inject drugs were continually involuntarily displaced compared with no displacement. Between 611 and 1360 additional people experiencing homelessness who inject drugs per 10 000 people were estimated to be hospitalized with continual involuntary displacement, and there will be an estimated 3140 to 8812 fewer initiations of medications for opioid use disorder per 10 000 people. Continual involuntary displacement may contribute to between 15.6% and 24.4% of additional deaths among unsheltered people experiencing homelessness who inject drugs over a 10-year period. Conclusion and Relevance: Involuntary displacement of people experiencing homelessness may substantially increase drug-related morbidity and mortality. These findings have implications for the practice of involuntary displacement, as well as policies such as access to housing and supportive services, that could mitigate these harms.