City streetscapes and neighborhood characteristics of fatal opioid overdoses among people experiencing homelessness who use drugs in New York City, 2017-2019

Background: While housing is a critical social determinant of nonprescription opioid overdose, little is known about how place impacts fatal overdose for people experiencing homelessness (PEH) who use drugs beyond the public versus private domains. This study investigated patterns of neighborhood environment features at locations of fatal overdoses among PEH.Methods: We remotely visited locations of opioid-involved fatal overdoses provided by the New York City Office of the Chief Medical Examiner, 2017-2019 ( n = 3276), with Google Street View and used systematic social obser-vation to assess characteristics of the street block related to drug exposures. We cross-referenced home address with city shelters and supportive housing to identify PEH ( n = 503). We used the differences of K functions from the spatial point patterns and kernel ratio function maps to identify geographic clusters. We then used logistic re-gression to identify significant individual-, block-, and neighborhood-level covariates (neighborhood deprivation, segregation, population density). Results: Over half (55.9%, n = 281) of fatal overdoses among PEH occurred in supportive housing or shelters, and 15.5% ( n = 78) occurred in public spaces (e.g., parks). Spatial analyses identified areas of significant concentrated fatal overdoses among PEH in Manhattan, the South Bronx, and Brooklyn. We identified several significant indi-cators of physical and social order and disorder associated with increased odds of experiencing homelessness at time of fatal overdose, including construction/renovation, graffiti, traffic calming features, and loitering.Conclusion: Harm reduction services should be co-located in facilities that serve PEH and targeted to street blocks with indicators of physical and social disorder. While supportive housing is a crucial step in preventing fatal opioid overdoses among PEH, identifying neighborhoods for intervention services delivery and harm reduction outreach for PEH is necessary.