Are States with Racial/Ethnic Inequalities in Homelessness Also States with Racial/Ethnic Inequalities in Overdose Deaths?

Background and Purpose: Although racial disparities in drug overdose mortality are well-documented in the United States (US), less is known regarding whether these overdose disparities are correlated with underlying racial inequalities in society. Informed by Fundamental Cause Theory (FCT), the present study examines state-level: a) racial/ethnic disproportionality in homelessness; b) racial/ethnic disproportionality in overdose deaths; and c) associations between racial/ethnic disproportionality in homelessness and in overdose mortality.

Methods: Counts of individuals experiencing homelessness (2015-2017; by state and racial/ethnic group) were obtained from the US Department of Housing and Urban Development; population estimates and counts of drug overdose deaths (2018-2021; by state and racial/ethnic group) were obtained from the National Center for Health Statistics. Homelessness and overdose mortality disproportionality scores were calculated to indicate the extent to which each racial/ethnic group was over- or under- represented among those experiencing homelessness, and among overdose deaths, respectively (relative to each racial group’s proportional share in the general population). For each racial/ethnic group examined, ordinary least squares regression models with robust standard errors (SEs) examined associations between state-level disproportionality in homelessness and disproportionality in overdose mortality, adjusting for percent aged 18-64 and US Census Region, as well as disproportionality in educational attainment and unemployment as covariates informed by FCT.

Results: With respect to disproportionality in homelessness, Black individuals were overrepresented in all states, American Indian/Alaska Native (AI/AN) individuals in 41 states, and Hispanic individuals in 25 states, whereas White individuals were not overrepresented in homelessness in any state or DC. Considering disproportionality in overdose deaths (for states with data available), overrepresentation was observed for White individuals in 38 of 51 (75%) states, Black individuals in 33 of 48 (69%) states, AI/AN individuals in 18 of 38 (47%) states, and Hispanic individuals in five of 51 (10%) states. State-level racial/ethnic disproportionality in homelessness was significantly and positively associated with racial/ethnic disproportionality in overdose mortality for Black (b=0.16 [SE=0.05]; p<0.01), American Indian/Alaska Native (b=0.71 [SE=0.23]; p<0.01), and Hispanic populations (b=0.17 [SE=0.05]; p<0.01) in models adjusting for region and percent aged 18-64. The significant positive associations in these three populations persisted after adjusting for educational attainment disproportionality, yet the association was no longer significant in the Black population after adjusting for unemployment disproportionality.

Limitations: The study’s data sources are limited by underreporting of homelessness, misclassification of race/ethnicity, and the lack of more detailed measures regarding homelessness circumstances and racial/ethnic identifications. This observational study was not able to provide evidence of causal relationships or examine all competing explanations for the association between racial/ethnic disproportionality in homelessness and overdose mortality.

Conclusions: Study findings support equity-focused responses to homelessness, overdose, and their underlying social determinants as priorities for federal and state policies, regional collaborations, and local community interventions. Findings highlight the importance of using a race-conscious lens to regularly evaluate the extent to which interventions and policies produce equitable social impacts, while designing programs in consideration of the specific circumstances and individual, contextual, and structural risk factors most relevant for groups overrepresented in homelessness and overdose deaths.