In 2023, for the first time, more than half of those who died while experiencing homelessness in Washington, D.C., died of an opioid overdose.
The percentage of homeless residents dying of opioid overdoses had been climbing for over 10 years. Fifty-seven percent of homeless deaths were due to opioid overdoses in 2023, up from just 6% in 2014, D.C. Office of the Chief Medical Examiner (OCME) data shows. Throughout the last 10 years, at least 393 homeless people died from an opioid overdose. This death toll is as staggering as it is preventable, advocates and experts say.
The urgency of the opioid epidemic has largely dissipated from the national discourse years after states won billions of dollars in settlements against the pharmaceutical companies and their owners responsible for the rush of opioids into many communities.
But, D.C. continues to struggle. The District has the second-highest opioid overdose mortality rate in the country, second only to West Virginia.
While in 2024, opioid overdose deaths were down in the city, it’s not yet clear if the same is true for people experiencing homelessness. This demographic has borne the brunt of the opioid epidemic’s burden on the District, dying at much higher rates than the city’s general population.
Nationally, the Trump administration has proposed sweeping cuts to federal funding which would restrict the District’s already strained overdose prevention resources. For decades, small nonprofit organizations have been at the forefront of the fight against overdoses and the implementation of harm reduction services, but they say cuts to federal grant money and health care funding would greatly reduce their capacity to curb deaths.
A proposed budget obtained by The Washington Post revealed that the Department of Health and Human Services (HHS) is facing more than $40 billion in cuts, including the termination of a $56 million grant that distributes Narcan and trains first responders on how to use it. The Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency devoted to researching and expanding access to mental health and substance use disorders, is also facing cuts greater than half of its budget. Between 2014 and 2025, the District and its service providers received almost $500 million in grants from SAMHSA.
The appointment of Robert F. Kennedy, Jr., a self-described “former heroin addict,” to the role of HHS secretary has further rattled addiction services providers and the recovery community. During his failed presidential campaign, RFK Jr. released a documentary proposing his plan to solve the country’s “addiction crisis.” The film lays out several policy proposals, including “wellness farms,” where people with substance use disorders would be corralled on farms away from their communities as a form of recovery. This is not considered to be an evidence-based treatment for addiction.
During his appointment hearing before the Senate, RFK Jr. endorsed Medications for Opioid Use Disorder (MOUD), a treatment method through which people receive medications like methadone or buprenorphine to help reduce cravings and withdrawal symptoms, before quickly pivoting to say that 12-step recovery programs are the “gold standard” for addiction treatment. This is not the case, according to leading experts.
According to a report released last month by a House Democratic Joint Economic Committee, more than one million people received MOUD through Medicaid in 2022. At least 60% of these people had coverage through Medicaid Expansion, a program that is now at risk of being cut or reduced by the Trump administration. In D.C., more than half of people receiving MOUD through Medicaid are eligible under Medicaid Expansion.
Part of the justification for these potential cuts is the nationwide decline in overdose deaths from 2023 to 2024. D.C.’s deaths declined by more than 35% in 2024, but the opioid-related mortality rate remains high. Overdoses increased substantially during the COVID-19 pandemic in 2020 and continued rising after. Preliminary 2024 overdose deaths in D.C., which have yet to be finalized by the OCME, are higher than at any time before the pandemic. Three times more people died of an opioid overdose in 2024 than in 2014.
Fentanyl, a highly addictive and powerful synthetic opioid often found in street drugs, largely accounts for the rise in opioid deaths among the homeless, experts say. It entered the drug supply around 2013, and today, it is present in most drugs available on the street, according to Dr. Elizabeth Nesoff, who researches substance use at the University of Pennsylvania. In 2023, fentanyl was found in more than 97% of people who died from opioid overdoses in D.C., according to OCME data.
“I don’t think you can declare something fixed when it is still happening,” Nesoff said.“When you cut services, the most vulnerable people are always going to be the most affected, and who is more vulnerable than the homeless?”
Stemming the tide of deaths
Rachelle Ellison thought she knew how she was going to die: alone, on the street, like many of her friends.
In 2008, she was locked in a cycle of addiction and living on the streets. One miscalculated dose or a bad batch of the substances her body craved could have ended her life. Today, she is a peer mentor, activist, and member of several D.C. agencies providing support for people experiencing homelessness and addiction.
“I myself was homeless for 17 consecutive years with co-occurring disorders, and for a very long time, I thought I was going to die in the street. I didn’t think there was going to be any help for me,” Ellison, who is also currently a Street Sense vendor said.
With the help of community outreach organizations, including Friendship Place, she entered housing in 2008. But she kept using substances.
“I knew there had to be a different way to live,” Ellison said. In May 2014, she entered detox, joined a 12-step program, and began working through her trauma and relationship with God, Ellison said.
Ellison entered recovery before fentanyl became widespread in the drug supply. Even then, detox and withdrawal felt like “death,” she said. Being housed helped, though, giving her a place to retreat from the world while in the early stages of recovery.
Addiction recovery can be especially difficult for people experiencing homelessness. A lack of daily activity can increase the odds of an individual turning to drugs, said Johnny Bailey, who directs an outreach program at HIPS (Honoring Individual Power and Strength), a small nonprofit that offers harm-reduction services. This can be especially true if someone is dealing with the chronic stress of homelessness and living in an encampment or shelter where other people may be using, too. Homelessness is notoriously lonely and, in Bailey’s words, boring.
“It is almost always easier to get dope than it is to get help. And as long as it’s easier to get dope than help, as long as dope is available at 2 a.m. in the encampment, and suboxone is somewhere you have to go to or MAT [medication-assisted treatment] at a certain time on a certain day, it’s a struggle,” Bailey said.
The American Society of Addiction Medicine and the American Medical Association consider Medications for Opioid Use Disorder (MOUD), including suboxone, methadone, and buprenorphine, as the gold standard for treating opioid addiction. These drugs prevent dangerous withdrawal and calm opioid cravings, lowering the risk of overdose among those who continue to use opioid substances. MOUD, low-intensity opioids themselves, do not produce feelings of euphoria like their illicit counterparts. Dispensed by medical professionals and heavily regulated by state governments, decades of research have deemed their use safe and effective.
“We assume that they’ve reduced their need for other opioids during the week,” Dr. Edwin Chapman said of the effects of medication-assisted treatment. Chapman has practiced medicine in the District for over 50 years and administered MOUD for 25. “So if they were using every day, maybe they are using every other day. If they’re using three or four times a day, maybe they’re using once a day.”
These treatments are free via Medicaid, but they can be difficult to access. Doses must be taken every day, and most MOUD clinics begin dispensing medication at 5 a.m. and stop around noon. Bailey’s favorite quip? “I have a joke about methadone, but you’ll have to be here at 6 a.m. Monday to hear it.” Reliable dosing can be made harder by the pressures of experiencing homelessness, like not having reliable transportation or full control over access to shelter and meals.
MOUD “doesn’t totally eliminate [the risk of overdose], but it reduces the risk significantly,” Chapman said. Studies have estimated that buprenorphine, the drug Chapman largely prescribes, reduces the risk of overdose in users by up to 80%. It is now available as a once-daily pill and a weekly or monthly injection. Injections give patients more freedom to work, travel, and live functional lives without being shackled to the daily routine of going to a methadone or buprenorphine clinic, but due to cost and a lack of licensed providers they are not always available.
Despite decades of demonstrated effectiveness, MOUD and harm reduction remain controversial to some in the recovery community. Although Ellison benefited from some harm reduction services while she was homeless and experiencing addiction, she ultimately credits her sobriety to detox, a 12-step program, and her Christian faith. Today, she remains a critic of some harm reduction programs.
Still, she recognizes not everyone is ready to enter recovery, or can dedicate time and resources to getting sober.
“There’s people that aren’t going to stop using and there’s people that are going to die,” Ellison said. “From a clinical perspective, I agree that [harm reduction services] are needed.”
Bailey is a champion of the harm-reduction approach. Formerly addicted to amphetamines, Bailey now directs an outreach program at HIPS, and he and his team say their approach saves lives.
“Wouldn’t you want people to stay alive one more day, one more minute, so they have the chance to make the right choice? Why not?” Diego Molina, a HIPS hotspot team member who works with Bailey, said.
Federal grants support direct service organizations like HIPS. Unlike 12-step programs, which tend to support an abstinence-only approach to substance use, harm reductionists believe that making substance use safer will save lives. Through street outreach, HIPS staff distribute supplies like fentanyl and xylazine test strips, clean syringes, and the overdose reversal drug Narcan. For HIPS, every interaction is a chance to keep someone alive and give them the opportunity to choose another path.
“I owe the universe a debt. I came from all the way down,” Bailey said. “I have two career goals: create the resources I wish I had when I was using, and try to extend the privilege I know I have.”
Bailey and his team spend significant time at hotspots in Southwest D.C. and Shaw distributing harm reduction supplies, snacks, and referrals to housing, medical, and recovery services — rain or shine. They also lead SMART recovery groups, an alternative to spiritually-based 12-step programs like Narcotics Anonymous.
“The only solution is to create a space for people to be,” Bailey said. Amidst the criminalization of drug use and the physical struggle of addiction, many experts agree facilitating the safe use of substances saves more lives than abstinence programs alone.
The first HIPS hotspot in the Shaw neighborhood helped create a 35% reduction of non-fatal overdoses in the area and a 54% reduction in the direct vicinity, according to Bailey. As part of their community outreach work, HIPS cleans up drug-related items, including used syringes, from the street.
“That doesn’t mean that there’s less people doing drugs, and it doesn’t mean that there’s less people overdosing. What it means is there’s less people calling 911, because we’ve empowered the community to take care of it themselves,” Bailey said.
Increased availability of Narcan, the overdose reversal drug HIPS distributes, was foundational to reducing opioid overdose deaths, according to the Centers for Disease Control and Prevention. In the District, first responders administered naloxone more than 243,000 times from April 2024 to April 2025, according to publicly available records; it’s life-saving progress, but federal funding for equipping first responders with the overdose-reversal tool could be cut.
As the Trump administration weighs slashing the federal health care funding that enables harm-reduction practices like Narcan and MOUD, Americans on the margins could suffer the most. Ellison and Bailey’s efforts to reduce the lethality of addiction in D.C. are largely supported by local and federal grants, but now their hard-won progress has now been thrust into jeopardy.
“Your solution can’t be, ‘well I hope these people die,’” Nesoff said.
