Abstract
IMPORTANCE: Many US communities face a crisis of people experiencing unsheltered homelessness often intertwined with opioid use. Jurisdictions seek policy options for managing unsanctioned encampments of this population, but their various outcomes are unclear. OBJECTIVE: To evaluate policy options and their health and economic outcomes for an encampment of people experiencing homelessness and opioid use disorder (OUD). DESIGN, SETTING, AND PARTICIPANTS: This decision analytical model study conducted a closed-cohort state-transition simulation using the Researching Effective Strategies to Prevent Opioid Death (RESPOND) model from October 2021 to October 2022. The study was based primarily on data from Massachusetts and simulated an urban encampment with a population experiencing homelessness and high-risk opioid use. Data analysis was performed from December 2022 to October 2024. EXPOSURE: The following encampment management strategies were modeled: (1) status quo (no sweep); (2) sweep, a sudden disruption of all residents, followed by no additional resources; (3) housing with medication for opioid use disorder (MOUD) requirement; or (4) housing without MOUD requirement. MAIN OUTCOMES AND MEASURES: The primary outcomes were overdose and all-cause mortality per 1000 person-years, weeks spent in housing and taking MOUD, and economic cost from a modified government payer perspective. Sensitivity analyses were conducted by varying uncertain parameters. RESULTS: The simulated cohort included 400 adults (mean [SD] age, 48 [17] years; 232 males [58.0%]). Under the status quo strategy, there were 50.4 (95% uncertainty interval [UI], 48.9-52.2) deaths per 1000 person-years, 15.5 (95% UI, 14.0-17.2) deaths from overdose per 1000 person-years, and 2990 (95% UI, 2897-3081) person-weeks spent taking MOUD for a total cost of $6 583 000 (95% UI, $6 502 000-$6 660 000). A sweep strategy resulted in 53.1 (95% UI, 51.3-55.2) deaths per 1000 person-years, 16.4 (95% UI, 18.2-20.2) deaths from overdose per 1000 person-years, and 1694 (95% UI, 1625-1764) person-weeks spent taking MOUD at a total cost of $6 820 000 (95% UI, $6 736 000-$6 899 000). The housing with medication requirement strategy resulted in 51.2 (95% UI, 49.4-53.0) deaths per 1000 person-years, 16.3 (95% UI, 14.6-18.1) deaths from overdose per 1000 person-years, and 3050 (95% UI, 3025-3075) person-weeks spent taking MOUD and in housing, for a total cost of $7 264 000 (95% UI, $7 188 000-$7 336 000). A housing without MOUD requirement strategy resulted in 49.2 (95% UI, 47.6-51.1) deaths per 1000 person-years, 14.3 (95% UI, 12.7-16.2) deaths from overdose per 1000 person-years, and 5014 (95% UI, 4942-5085) person-weeks spent taking MOUD and 14 511 (95% UI, 14 461-14 562) person-weeks spent in housing, for a total cost of $8 822 000 (95% UI, $8 774 000-$8 868 000). CONCLUSIONS AND RELEVANCE: In this decision analytical model study of approaches to homeless encampments involving individuals with OUD, sweeps increased mortality and spending. Housing without MOUD requirement was the most costly strategy but saved more lives.