The Contribution of Homelessness to Opioid Overdose Mortality and Associated Racial Disparities.

To elucidate the role of housing status in observed racial disparities in opioid overdose mortality, we conducted a cross-sectional study using vital statistics, medical, and housing records in San Francisco, California from 2021 to 2023. We reported standardized mortality ratio (SMR); indirectly age- and sex-standardized mortality rate; and observed, expected, and excess deaths for each race or ethnicity group among people experiencing homelessness, using adult Californians as the standard population. Forty-seven percent (812/1727) of overdose decedents were recently homeless, and people experiencing homelessness had 33 times the rate of opioid overdose mortality (SMR 33.2, CI 29.1-37.3) compared to the general population, standardized by age, race, and sex. There were a minimum of 244 excess deaths per year in San Francisco due to the increased risk of overdose among people experiencing homelessness, which disproportionally affected Black people. Reducing opioid overdose mortality and related disparities requires addressing the housing crisis.