To the Editor: Dr. Lanham and colleagues provide a broad overview of homelessness in the United States and the associated medical considerations.¹ We would like to highlight the role of community health centers and the importance of addressing substance use disorders using a harm reduction framework.

Community health centers collectively serve more than 1 million patients experiencing homelessness each year.² Support from federal, state, and local grants provides multidisciplinary medical, behavioral health, and case management services at shelters, outreach vans, community centers, houses of worship, soup kitchens, and on the street. Physician’s presence in these non-traditional settings provides dignified, accessible medical services and, as the authors note, avoids inefficient use of emergency departments for nonemergent conditions.

Although most people experiencing homelessness do not have a substance use disorder and most people with substance use disorder do not experience homelessness,³ substance-related complications account for a significant share of morbidity and mortality among the homeless population. Researchers from Boston Health Care for the Homeless Program found that drug overdose replaced HIV as the leading cause of mortality among homeless adults served from the early 1990s to the mid-2000s.⁴ Through 2018, overdose-related mortality in this population continued to increase and was 12 times higher than in the general population of Massachusetts.⁵

This reality underscores the importance of embedding low-threshold and accessible harm reduction and recovery services within health centers serving people who use drugs. Evidence-based harm reduction approaches include naloxone distribution, syringe service programs to decrease transmission of viral and bacterial infections, and sedation monitoring.⁶ These interventions complement the low-threshold availability of substance use disorder treatment, including buprenorphine and linkage to methadone treatment, hepatitis C and HIV treatment and prevention, and contingency management.

We applaud the focus on a vulnerable population and further highlight the essential and multidisciplinary services that community health centers provide to address the disparate effect of substance use disorder on people experiencing homelessness.

Editor's Note: This letter was sent to the author of “Care of People Experiencing Homelessness,” who declined to reply.