In the late ‘80s and early ‘90s, HIV was a major killer of homeless adults in Boston, accounting for about 18 percent of deaths among more than 17,000 people treated by Boston Health Care for the Homeless over five years. With greater awareness about HIV infection and outreach programs to those at risk, the death rate from the disease has declined.
In a new study of 28,033 adults treated by the organization between 2003 and 2008, there were 1,302 deaths and HIV accounted for less than 6 percent, according to a study. That’s the good news.
The bad: A new threat has risen to take its place. Nearly 17 percent of deaths were caused by drug overdose, with opioids such as heroin and narcotic painkillers implicated in four out of five of those, the study published this week in the journal JAMA Internal Medicine found.
Opioid use has become a problem statewide. But among the young and homeless the rate of drug overdose is particularly alarming, said Dr. Travis Baggett, lead author and a staff physician at Boston Health Care for the Homeless.
People ages 25 to 44 had a mortality rate about nine times higher than for the broader state population in that age group. Deaths from overdose among homeless men and women of those ages occurred 16 and 24 times more often than in the comparable demographic statewide.
“There’s no single right answer to solving this problem,” Baggett said.
But Boston Health Care for the Homeless is trying. It plans to train staff at clinics and shelters on how to use a drug that can reverse an overdose and to distribute it to people at risk for one. It also is expanding use of buprenorphine to treat opioid dependence, Baggett said, and looking for ways to effectively treat chronic pain with less reliance on prescription painkillers, such as offering more physical therapy.
The bigger challenge is improving behavioral health, including support for those with addiction, throughout society, he said.
At the center of all of those efforts is the basic tenet that addiction is a disease.
“Culturally, we have a tendency to view substance use as a character flaw, as a personal problem, that somehow drug overdose is representative of bad people behaving badly,” Baggett said. “We wholeheartedly reject that viewpoint.”
Robyn Frost, executive director of the Massachusetts Coalition for the Homeless based in Lynn, said she had not seen the study but she was not surprised by the main findings that mortality for this population had remained about level and that opiate overdose had become a significant threat.
“It’s just a spillover of what’s happening in our bedroom communities,” she said, referring to increased drug use.
Frost said the last few years have been hard on people living in poverty, driving many to homelessness and depression, and making them more susceptible to substance use.
“The level of despair in this state has hit unbelievable, palpable – it’s nothing that we’ve seen” before, she said.
Cancer and heart disease were the second and third leading causes of death among the Boston Health Care for the Homeless patients. And while HIV accounted for fewer deaths overall, it continued to be a far bigger threat to homeless adults than it is for the broader state population. Among men ages 25 to 44, the mortality rate from HIV for those who were homeless was 17 times what it is for the state overall.