The Los Angeles County Department of Public Health has released its fifth annual report on mortality among people experiencing homelessness in Los Angeles County. From 2021 to 2022, the most recent years of data available for the report, the overall mortality rate increased by just 2% from 3,215 per 100,000 people to 3,282 per 100,000 people.  This is a welcomed plateauing of the mortality rate among people experiencing homelessness, which previously saw a devastating increase of 56% from 2019 to 2021.

The recent plateau in the overall mortality rate can be attributed largely to a leveling off of the rate of drug overdose deaths, the leading cause of death among PEH for the past six years, and a sharp decline in COVID-19 mortality. From 2021 to 2022, the distribution of doses of naloxone, an opioid overdose reversal medication, saw a two-and-a-half-fold increase in communities most affected by fentanyl overdoses, and the number of reported naloxone-induced overdose reversals nearly doubled. These efforts likely contributed to the rapid leveling-off of the overdose mortality rate in 2022.

Leading Causes of Death

Overdose

Drug and alcohol overdose continues to be the leading cause of death among unhoused individuals in 2022, accounting for 37% of all deaths. Overdose was the leading cause of death among males and females, and among Whites, Latinx, and Blacks. Despite the recent leveling off of the overdose mortality rate among people experiencing homelessness, the percentage of overdose deaths involving fentanyl continued to rise through 2022 for all racial and ethnic groups and for both males and females, signifying. that the risk of fentanyl overdose is very high among unhoused people who use drugs.

Coronary Heart Disease

The second leading cause of death continues to be coronary heart disease, accounting for 12% of deaths. Coronary heart disease was the leading cause of death among those 70 and older, the second leading cause of death among males, and the third leading cause among females. After a gradual upward trend in coronary heart disease mortality from 366 per 100,000 people in 2014 to 445 per 100,00 people in 2020, the coronary heart disease mortality rate decreased in 2021—during the height of the COVID-19 pandemic—and then increased slightly in 2022 to 395 per 100,000 people.

Transportation-related injuries

In 2022 8% of deaths were from transportation-related injuries, which remained the third leading cause of death among unhoused individuals. The transportation-related injury mortality rate plateaued in 2022 after increasing steadily from 2014 to 2021. Assuming a relatively stable distribution of road traffic deaths among people experiencing homelessness over time, one of these deaths occurred approximately every other day over the course of 2021 and 2022. Ninety-five percent of those deaths were among pedestrians and cyclists and two-thirds occurred between 9 p.m. and 9 a.m.

Homicide

Homicide was the fourth leading cause of death, with a rate of 214 per 100,000 people in 2022, the highest rate since these trends have been monitored. The proportion of homicide deaths was more than twice as high among males compared to females and was two to three times higher among Black and Latinx unhoused people compared to White unhoused individuals. In 2021 and 2022, two-thirds of homicide deaths involved firearms.

Suicide

The overall suicide rate among people experiencing homelessness has remained relatively stable over time. However, from 2020 to 2022 the suicide rate almost doubled among unhoused people aged 18-29, and in 2022 this was the age group with the highest suicide rate. In 2021 and 2022, 5% of suicide deaths involved firearms.

COVID-19

The COVID-19 mortality rate peaked in 2021 when it was the fifth leading cause of death among people experiencing homelessness. In 2022, the COVID-19 mortality decreased substantially such that it was no longer among the top 10 causes of death among unhoused people that year.

Mortality rates of people experiencing homelessness compared to the general LA County population

For the combined years of 2021 and 2022, people experiencing homelessness were almost four times more likely to die than the LA County population as a whole. This mortality gap has increased since it was first analyzed for the combined years of 2017 to 2019, when people experiencing homelessness were slightly under three times more likely to die.

The mortality gaps for specific causes of death have also increased. In 2021-22, unhoused individuals were 41 times more likely to die from an overdose and about 18 times more likely to die of both homicide and traffic-related injuries compared to all LA County residents.

“The mortality rates among people experiencing homelessness are a tragedy for our entire community,” said Supervisor Lindsey P. Horvath, Chair of the Los Angeles County Board of Supervisors. “While it is welcomed news to see a plateau in the overall mortality rate of drug overdoses, we must continue to invest in solutions that reduce mortality. This report is a call to action to urgently bring people indoors and into permanent housing and services — the only way to save lives and end this crisis.”

“Year after year, we continue to see the impacts of substance use on our unhoused neighbors. As the leading cause of death among people experiencing homelessness, it is critical that the County continue to invest in solutions that meet the needs of this community. That is why I am working to open a Harm Reduction Health Hub on Skid Row, the epicenter of the overdose crisis, to ensure residents get the resources they need to address this behavioral health crisis,” said Supervisor Hilda L. Solis.

“This report further highlights why housing is a human right,” said Supervisor Holly J. Mitchell. “We must continue to expand on the proven strategies and recommendations outlined in this report that have helped stop the rising mortality rate among unhoused residents, including increased access to supportive and long-term housing with on-site services to meet the needs of our unhoused family, friends, and neighbors.”

“This report is cold comfort, and no one is celebrating a ‘plateauing’ in mortality rates,” said Supervisor Janice Hahn. “Homelessness is deadly and, while we need to double down on harm reduction and street medicine programs, what we really need is to get people off the street and into safe housing.”

“Although 2022 mortality rates among people experiencing homelessness have plateaued after two consecutive years of alarming increases, this report highlights the continued need for concerted efforts to reduce the disproportionate burden of mortality among this vulnerable population,” said Barbara Ferrer, Ph.D., M.P.H., M.Ed., Director of the Los Angeles County Department of Public Health. “The growing mortality gap between unhoused individuals and the LA County population underscores the need to implement targeted strategies that provide comprehensive resources and services for people experiencing homelessness.”

“After alarming increases in drug-related overdoses over the past several years, it is encouraging to see a slowing of this leading cause of death for people experiencing homelessness. Efforts to increase access to naloxone and overdose prevention services have undoubtedly helped to bend this curve and provide a blueprint for reducing drug-related fatalities in this very high-risk population,” said Dr. Gary Tsai, Director of the Bureau of Substance Abuse Prevention and Control. “Given that the opposite of addiction is not sobriety, but rather meaningful connection, continuing to engage and build trusting relationships with our unhoused residents will be equally essential.”

Recommendations

In collaboration with community partners, Public Health recommends the following actions to help reduce the disproportionate burden of mortality among unhoused individuals:

 – Ensure unhoused individuals are linked to housing options aligned with their individual needs by regularly training staff providing outreach and engagement services, and physical health, mental health, substance use, and social services for residents experiencing homelessness, on the most current versions of the Homeless Management Information System tools.

– Sustain and expand the range of permanent and supportive housing options that are responsive to the needs of LA County residents experiencing homelessness, such that people who use drugs will not lose their housing due to substance use.

– Sustain and expand harm reduction and overdose prevention and response services, prioritizing residents experiencing homelessness at highest risk for overdose, through legislation, regulation, local engagement, and advocacy.

– Increase street-based engagement and outreach, low-barrier drop-in spaces, and expand telehealth and mobile services to ensure substance use, mental health and physical health services are accessible to people experiencing homelessness.

– Sustain and expand access to comprehensive primary and preventive care, mental health, and substance use services, across all community and congregate settings for residents experiencing homelessness.

– Support the development and expansion of comprehensive wrap-around services tailored to the special needs of unhoused individuals to increase access to chronic disease management, including cardiac care.

– Collaborate with municipalities and unincorporated communities to identify concentrations of fatal injury collisions involving residents experiencing homelessness to inform community planning and strengthen local infrastructure, programming, and policy interventions that can prevent future traffic deaths.

Data used

These annual reports use data from the L.A. County Office of Medical Examiner and California state death records to estimate numbers of deaths among people experiencing homelessness, as well as data from the annual LA County point-in-time homeless count and demographic survey to estimate numbers of people experiencing homelessness and their demographic characteristics.  The next report, to be released in early 2025, will include data through 2023.

To view the full report online, visit: http://publichealth.lacounty.gov/chie/