The Multnomah County Health Department’s annual review of deaths among people experiencing homelessness has found that during calendar year 2023, at least 456 people died without a home of their own.

The number, significantly more than the 315 deaths reported in 2022, is the highest since Multnomah County began its analysis — reflecting what health officials believe is the height of the fentanyl crisis that swept our community in 2023.

Of the 456 deaths, 251 were linked to fentanyl, roughly triple the number reported in 2022 and a clear sign of the synthetic opioid’s deadly impact. Overdose deaths in 2023 overall climbed to 282 people, more than double the 123 deaths reported in 2022.

“The devastating toll fentanyl is taking on our community is starkly apparent in this report and it is heartbreaking,” said Multnomah County Chair Jessica Vega Pederson. “This is a moment for our community to grieve alongside more than 450 families who lost loved ones in 2023 and to continue providing and fighting for more behavioral health, supportive housing and other resources to respond.”

Multnomah County Health Officer Dr. Richard Bruno said the 2023 numbers reflect the devastating toll of fentanyl that has begun to lessen in 2024, following a local and state emergency declaration to address the crisis and other national changes.

“The data in this report are from 2023, which appears to be the peak of the fentanyl crisis in Multnomah County,” he said. “As we are seeing fentanyl overdose deaths decreasing in 2024, we are hopeful that future reports will hold much lower numbers.”

Dr. Bruno, who has spent years working with people with substance use disorder said, “For me, this report hits close to the heart. Many of the people outlined in this report were patients I cared for in clinic and I knew their stories well. These were people who fought incredible odds, facing barriers and adversity in healthcare and housing systems. Many struggled with an untreated substance use disorder or mental health problem, or suffered violent abuse or traffic fatality. In every case, we as a society could have done better to help people get the care and stability they needed.”

Each year the County’s Health Department undertakes the Domicile Unknown report to determine the number, characteristics and causes of deaths among people experiencing homelessness in Multnomah County. The goal of Domicile Unknown is to provide elected officials and the public an understanding of the primary contributions to the risks these community members face.

The report examines both the accidental or suspicious deaths investigated by the Multnomah County Medical Examiner — 394 — as well as the deaths of 62 people who died at the hospital or under medical care and whose deaths were tallied from certificates recorded by funeral homes.

Hospital and medical care deaths were included after Senate Bill 850 took effect Jan. 1, 2022, establishing mandatory reporting of housing status at death. This report is the second in Multnomah County to include kinds of deaths. Prior reports could not include that additional data because it was not available at the time.

Because Multnomah County was the first jurisdiction in Oregon to investigate deaths among people experiencing homelessness — starting with deaths in 2011 — the Medical Examiner can chart changes in that subset year over year.

The Medical Examiner found that deaths it has investigated among people experiencing homelessness have jumped 37% on average every year between 2019 and 2023.

The total of housed Multnomah County residents whose deaths are investigated by the Medical Examiner has also risen over each of the last five years. But nonetheless, people experiencing homelessness in 2023 were 58 times more likely to die from a transportation-related injury, 51 times more likely to die from a drug overdose, 18 times more likely to die from homicide, 18 times more likely to die from suicide and eight times more likely to die from any cause compared to the general population.

“Providing these data each year helps ensure that we don't overlook the risks associated with not having housing,” said Health Department Epidemiology Manager Dr. Emily Mosites.

A copy of the report is here.

Of the at least 456 people who died while experiencing homelessness in 2023, 349 (77%) were people assigned male at birth, and 107 (23%) were people assigned female. Their average age was 46 — more than 30 years younger than the age when the average Multnomah County resident might expect to die.

The largest proportion of deaths — 316 — was accidental or unintentional, 89% of which were from drug overdoses. Most people had multiple drugs in their system, with fentanyl (present in 89% of cases) and methamphetamines (present in 81%) the most common.

The numbers indicate just how quickly fentanyl’s impact spread. In the six years since fentanyl was first recorded as contributing to a death among people experiencing homelessness, one person died in 2017, then two each in both 2018 and 2019, followed by four in 2020, 36 in 2021, and 74 in 2022.

The increase in fentanyl-related deaths among people experiencing homelessness aligns with national trends, especially in the western United States, where fentanyl has become increasingly available.

The families of Nancy Hill, Colby Nutter and Joshua Lumley also shared their experience of losing a loved one to a drug overdose in this year’s report.

“He so badly wanted to quit and to be present with family,” Colby’s sister shared. “He tried so hard, but ultimately just couldn’t get to that place. We wish we could have helped him more, but he wore a shield that said, ‘I’m good, I can do this, I don’t want to be a burden.’”

Traffic deaths made up the second-largest number of accidental deaths, with 22 people dying from crashes, or 7% of all unintentional deaths. This also mirrors a national trend in which pedestrian deaths reported by the U.S. Department of Transportation have increased every year for the past five years.

A Multnomah County Health Department study of traffic crash deaths between 2012 and 2021 found that people experiencing homelessness face disproportionate risks, accounting for 24% of all traffic deaths in the County in 2020 and 2021. Researchers found the higher rate and risk of traffic deaths results from the combination of living in near-road environments and increased exposure by virtue of being outside much of the time.

Fourteen people were killed by someone else while experiencing homelessness in 2023, down from a record 25 homicides in 2022 and mirroring the decrease in homicides overall as reported by Multnomah County and the cities of Portland and Gresham. An additional 26 people died by suicide, which was an increase from the seventeen people reported in 2022.

On average, 38 people died each month. April saw the fewest deaths, 29, while the month with the highest number of deaths, 53, was March. One person died of cold exposure in January 2023. No deaths related to heat were identified.

While drug overdoses, traffic injuries and homicides were major factors, people experiencing homelessness also died of chronic disease, such as cancer and liver disease, and communicable diseases, including sepsis, HIV and hepatitis C.

“The key to me is getting people into housing and having services rushed to them to support them,” said Central City Concern Clinical Outreach Director Drew Grabham. “I look forward to one day not needing a Domicile Unknown report, but until then I think we have our work cut out for us.”

Housing and shelter — as well as the myriad other social, economic and environmental factors that underlie the causes of excess deaths among people experiencing homelessness — must continue to be considered when developing policies that can save lives and prevent premature death.

Source: Multnomah County

Tanner, Drew, & Laura