Background: People who use drugs and experience homelessness are targets of public discourse about urban decay and significantly vulnerable to overdose mortality.
Objectives: We explored responses to overdose and housing crises from the perspectives of diverse stakeholders, media reports, and policy documents.
Methods: POLY HOME employs longitudinal ethnographic and qualitative methods to examine the
contexts of fentanyl-stimulant polysubstance use among people experiencing homelessness (PEH) and patterns and overdose vulnerability among PEH in San Francisco and New York, US. We conducted qualitative interviews with representatives (n=50) from local and national stakeholder groups, including substance use and housing services and drug user-led organizations, and reviewed local media reports and policy documents. Data were coded and analyzed using a modified grounded theory approach.
Results: Stakeholders emphasized the need to document how the proliferation of fentanyl and new adulterants (e.g., xylazine) and rising fentanyl-stimulant polysubstance use shape overdose vulnerability as PEH navigate ongoing housing crises. While local media reports consistently framed fentanyl as “unprecedented” and “exceptionally dangerous”, stakeholders contested such framings by focusing attention on structural factors that exacerbate overdose vulnerability (e.g., poverty, housing vulnerability, access to evidence-based substance use treatment and harm reduction services). Stakeholders expressed concern that ‘fentanyl exceptionalism’ was driving policy responses unsupported by evidence, such as criminalization (e.g., street sweeps, arrests) and mandated substance use treatment.
Implications: ‘Fentanyl exceptionalism’ intersects with homelessness to potentially drive punitive approaches to substance use and urgent attention toward underlying structural dynamics driving overdose vulnerability is needed.