Drug overdose was the leading cause of death among homeless adults in Boston from 2003 to 2008 and accounted for one-third of deaths among those ages 25 to 44. A study by investigators from Massachusetts General Hospital (MGH) and the Boston Health Care for the Homeless Program (BHCHP) compared rates and causes of death among those served by BHCHP with data from a similar 1997 study and found that, while drug overdose had replaced HIV as the leading cause of death, overall mortality rates had not changed.
"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," says Travis Baggett, MD, MPH, of the MGH Department of Medicine and BHCHP, who led the study. "Overall, young homeless people died at a nine times higher rate and middle-aged homeless people at a four-and-a-half times higher rate than comparably aged adults in Massachusetts." As a 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 current study, which will appear in the Feb. 11 issue of JAMA Internal Medicine (formerly Archives of Internal Medicine) and is receiving early online release, updates the previous study that covered the years 1988 to 1993. That report found that HIV was the leading cause of death among BHCHP patients aged 25 to 44, while homicide was the principal cause among those 18 to 24. Heart disease and cancer were the leading causes of death in those 45 to 64. To update that data, the investigators analyzed available information for more than 28,000 adult patients who had received care from BHCHP from 2003 through 2008.
Drug overdoses accounted for almost 17 percent of all deaths among the homeless patients studied, and 81 percent of those overdoses involved opioid drugs. Cancer and heart disease – again the primary causes of death among older homeless individuals – each accounted for nearly 16 percent of deaths among the overall homeless population. Health issues associated with substance abuse – such as alcoholism-associated heart disease, pneumonia and withdrawal – accounted for 8 percent of deaths.
The significant drop in deaths from HIV infection was offset by the increase in deaths from overdoses and other substance-abuse-related issues, resulting in no change in the overall mortality rates from the earlier study. Overall mortality was higher in white individuals than in black or Hispanic homeless people, which – the authors write – may be due to a disproportionate burden of substance abuse and mental illness among white homeless individuals as compared to homeless minorities.
"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," says Baggett, who is also an instructor in Medicine at Harvard Medical School. "They also suggest that, while health care services like BHCHP can help improve the health of homeless people, they probably are not enough. Making a major impact on mortality for these patients will also require addressing the social factors that contribute to homelessness in the first place."
Nancy Rigotti, MD, of the MGH Department of Medicine is senior author of the JAMA Internal Medicine report. Additional co-authors are James O'Connell, MD, president of BHCHP and an MGH physician; Bianca Porneala, MS, and Daniel Singer, MD, MGH Medicine; Erin Stringfellow, MSW, BHCHP; Stephen Hwang, MD, University of Toronto; and John Orav, PhD, Brigham and Women's Hospital. Funding for the study includes National Institute on Drug Abuse grant K23DA034008 and American Cancer Society grant 122269-IRG-12-070-01-IRG.
Founded in 1985, Boston Health Care for the Homeless Program has evolved into the largest and most comprehensive health care for the homeless program in the country, delivering services to more than 11,000 homeless men, women and children a year in two major teaching hospitals and more than 80 shelters and other sites.
Massachusetts General Hospital (www.massgeneral.org), founded in 1811, is the original and largest teaching hospital of Harvard Medical School. The MGH conducts the largest hospital-based research program in the United States, with an annual research budget of more than $750 million and major research centers in AIDS, cardiovascular research, cancer, computational and integrative biology, cutaneous biology, human genetics, medical imaging, neurodegenerative disorders, regenerative medicine, reproductive biology, systems biology, transplantation biology and photomedicine. In July 2012, MGH moved into the number one spot on the 2012-13 U.S. News & World Report list of "America's Best Hospitals."