Shelter, Safety, and Survival in People Who Use Drugs in Unhoused Communities

People who use drugs (PWUD) with unstable housing are heavily affected by their spatial placement. Effects include drug usage patterns, risk of overdose, and access to harm-reduction supplies like clean needles, Naloxone (Narcan), “cooking” supplies, and more. Government sanctioned encampment clearances alter geographies of drug use, primarily forcing individuals into isolated environments like alleyways or construction areas where overdoses can go unnoticed by the public. Places that are more in the public eye have fewer fatal overdoses but generate significant public disapproval. Due to public disapproval, structural failures like ‘drug-free zones,’ which prioritize visual displacement over actual rehabilitation of people in need, have been implemented. Inconsistent policies within the current political administration also take away resources from healthcare access and funding of nonprofits that provide programs and harm reduction resources. This contributes to the neglect of vulnerable populations, which further increases the substance abuse crisis rather than helps solve it. Overdoses continue to be one of the leading causes of death in people under 50, falling into the category of ‘unintentional injury’ according to the Centers for Disease Control (CDC) and National Institutes of Health (NIH), calling for accessible healthcare for the people. Case and Deaton commented that “by 2017 the annual number of overdose deaths was greater than the peak number of deaths from HIV, from guns, or from automobile crashes…greater than the total number of Americans who died in Vietnam…cumulative total from 2000 to 2017 is greater than the total number of Americans who died in the two world wars.”(Case, A. Deaton, A.) With overdose rates soaring, two main anti-drug courses of action have been tried, promoting abstinence aka “Just Say No”, and harm reduction. The “Just Say No” method was proven historically ineffective, especially during early education programs like D.A.R.E. and during the 1970s War On Drugs campaign. The successful harm reduction models, such as Skid Row Care Campus and syringe access programs, argue that expanding healthcare access rather than policing the physical presence of PWUD is the only path to saving lives. The most effective harm reduction models recognize that drug use is a very complex phenomenon with deeper physiological and psychological roots, and each individual PWUD has their own journey. Harm reduction is non-judgmental and non-coercive, and affirms PWUD as the people in power who can stop or slow the harms in their drug use, and encourages them to share resources, educate, and support each other. 

The number of people experiencing homelessness continues to grow in the United States, largely due to growing economic inequality, and many people end up living in clusters on the outskirts of heavily populated cities. Large groups of homeless people living in the same area draws attention, causing law enforcement to do ‘encampment sweeps’ where individuals are forced out of their makeshift homes. Sweeps also sometimes forcibly discard personal belongings, leaving individuals without basic necessities. After a sweep, people have to find a new place to settle, often seeking shelter in isolated alleyways or within construction scaffolding. Individuals have to find a new place to live before sundown without the community, shelter, and protection they had within their previous encampment. “Imagine someone kicking in the front door to your house, demanding that you leave, then trashing all your household possessions. That’s exactly what happens when police and city workers sweep a homeless encampment,” says David Peery of the National Consumer Advisory Board for the National Health Care for Homeless Council. In a study conducted in Massachusetts and published in the National Institutes of Health, of 155 PWUD, 38 experienced an encampment sweep; 73% of those 38 reported difficulty finding health and social services following a sweep. PWUD are more likely to be unhoused, and drug use is a method of coping that may increase with the stress following sweeps. With most major U.S. cities having criminalized lying and camping in public, populations of the unhoused try to find the most reliable places to live, which end up being the isolated places away from the public eye. In isolated areas, a wide array of adverse events can happen. This is why encampment sweeps are associated with “increased violence, syringe sharing, and reduced access to healthcare”. The loss of evidence-based overdose prevention supplies and the loss of the public eye’s protection means overdose numbers skyrocket, care is disrupted, and people lose hope and dignity. Two states currently have “Right to Shelter” laws, Massachusetts and New York. Right to Shelter laws are intended to provide basic shelter and necessities to people in need, but because these laws are not fully implemented and sweeps are still widely called for, shelter programs are overlooked and not prioritized by legal authorities and many are unaware or excluded from it. The Right to Shelter in Massachusetts is also very strict, only allowing emergency shelter to individuals who are pregnant, and people who have children under 21 and no possible alternative housing. The law in New York extends to all individuals, but is capped at a length of stay of 30 days and the person must adhere to health and safety standards during their stay. In the case of a sweep in a neighboring state, one could flee to New York and receive a migrant stay visa while settling, as opposed to fleeing into an unsafe isolated area, devoid of harm reduction resources.  If more states implemented the Right to Shelter, the need for encampment sweeps would decline, and people would be less geographically at risk. 

Due to the rising number of homeless encampments, the general public blame the rising numbers solely on substance abuse and form an automatic connection between the two, leading to them not feeling safe in public spaces with homeless activity. In a survey done by the Cicero Institute, 66% of Arizonans feel unsafe due to homeless encampments on city streets (Kurz). In 2024, Devon Kurtz wrote about Drug-Free Homeless Service Zones and their potential efficacy in keeping “unsheltered” PWUD out of the public eye. He includes a diagram which says “two-thirds of homeless people reported regularly using hard narcotics like methamphetamine, crack cocaine, and opiates” in bold, and in smaller print, “less than half of which reported ever receiving treatment.” This diagram highlights homeless people in association with hard narcotics, and seemingly intentionally ignores the fine print, the fact that PWUD have not received treatment. This raises the question, why haven’t these people received treatment? Is this pattern of avoiding treatment a coincidence, or does it point to a systemic flaw? While drug-free zones create a “safe” environment for those within the sheltered area, drugs still exist, will continue to exist, and creating a ‘out of sight out of mind’ zone for the public will not solve the issue at hand. Drug-free zones prioritize the visual displacement of “scared” individuals and the law enforcement called to do encampment sweeps, while ignoring the root of the fact that struggling individuals with nowhere to go are using city sidewalks as refuge as a last resort. In Breaking the Taboo, a film about the War on Drugs, the film interviews Dr. Peter Moskos, a criminologist and former police officer who talks about an area he used to police, “men who are born there have a 12% chance of getting murdered in their lifetime,”(Moskos). This is in reference to the gang violence that comes as a result of drugs and criminal activity due to positive feedback loops of policing that favor visual displacement instead of rehabilitation. “It seems like these problems are far more important than some sort of futile goal of creating a drug-free society…people should care more…the vast majority [of drug related crime] are related to prohibition.” he says. When people do not get the help they need, drug use becomes centralized, leading to communities ride with gang violence, drug use, and other crimes. This leads to areas such as Skid Row in Los Angeles, California, Colfax Avenue in Denver, Colorado, and downtown Las Vegas, Nevada, which are known as ‘tent cities’. Tent cities are widely known notorious areas in major cities across the US. 

The Trump Administration during its term has proposed budget cuts to the National Institutes of Health and the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Drug Control Strategy (NDCS), published in 2026, also does not align with the administration's current or [Trump’s] past actions. For example, the NDCS encourages making treatment accessible for everyone; however, cutting Medicaid and canceling funding to drug research works against the goals set out in the strategy. The federal administration is also moving funding away from harm reduction, such as needle exchanges and test strips to detect fentanyl and other harmful substances, and redirecting the money towards the abstinence-only focused treatment, a style of treatment that is less effective than harm reduction. Public officials and communities sometimes see harm reduction as “enabling” addiction; however, this is a common misconception. Harm reduction is not the opposite of recovery but “a bridge between addiction and recovery”(SAFEProject). The “Just Say No” movement was taught to children in schools in the 1980s and 90s, calling for people in any situation to just “say no” to substances. However, this generation was unable to abstain, proven by the ever-increasing number of overdoses because they were never taught the social skills required to “just say no”. Harm reduction has momentum in other countries, with over 112 countries supporting it in their national policies today. Switzerland opened the world’s first drug consumption rooms, where people could take drugs with supervision with clean supplies, mainly for heroin addicts, which in turn caused a sharp decline in black market activity, crime, and overdoses. The United States has nonprofits and organizations that support harm reduction goals, but the federal government remains relatively pro-abstinence, increasingly so under the Trump administration.

Successful harm reduction models keep people who use drugs “safe and alive” (Schrank), which aim to give PWUD proper resources and education, instead of contributing to the growing stigma around homelessness and drug usage that can often increase risks of overdose, leading to unsafe practices. The National Harm Reduction Coalition details the principles of harm reduction as strategies and ideas that reduce negative consequences associated with drug use. The Harm Reduction movement takes the principles into practice and incorporates safer, managed use, “meeting PWUD where they are at” (National Harm Reduction Coalition). In a YouTube video by Soft White Underbelly titled “The Job of Knowing Everything - Brandon Novak (follow up),” Novak details his struggles with addiction to heroin and cocaine, living homeless, and prostituting himself for money. One day, he walks past a harm reduction clinic offering money in exchange for blood work; they pay you to get blood drawn, and they also pay you to come back and get results. He gets his blood drawn, gets his first paycheck, and swears he won’t go back, remaining ignorant to the diseases he may or may not have picked up along his journey of addiction. When he walks back in for his results, when he is in dire need of money, he discovers he has Hepatitis C. Without visible harm reduction advertisements in ‘tent cities’, many people are at risk of death from pathogens like Hepatitis, HIV/AIDS, and tuberculosis. Skid Row, a tent city in Los Angeles, California known for its large impoverished, addicted, unhoused population, opened up Skid Row Care Center in April of 2025. Skid Row Care Center (SRCC) functions as a harm reduction, healthcare, and support service center where residents can receive residential living, healthcare, and social services. If every major tent city had a care center similar to SRCC, residents would feel safer, have easier access to healthcare and in turn overdoses and disease risk would decrease. 

Under the Trump administration, the substance abuse crisis remains a widely criminalized public health issue. Instead of criminalizing the homeless population and any related drug activity as the government did to marijuana during the War on Drugs in the 70s, the government should prioritize the health of the people and treat unhoused PWUD as a humanitarian crisis. Advertising for harm reduction clinics and resources should be more visible, and encampment sweeps should not discard positive resources like Narcan, because in the past, harm reduction nonprofits have resorted to nailing Narcan to trees due to sweeps and a lack of distribution. The federal government can coordinate with police officers to enforce and allow people to exercise the Right-to-Shelter laws. This includes potentially getting the Right-to-Shelter laws instated in other states, as it is only present in two states currently and is beneficial for migrants and families. Hospitals and healthcare officials should communicate and coordinate with police and harm reduction organizations to distribute supplies and help educate the public about strategies to help them and their loved ones that are struggling, as well as risk of disease and publicizing test clinic locations. Managing homeless populations through policing does not eliminate the substance use epidemic surrounding unhoused PWUD; it simply veils the issue from the public. Progress relies on treating the homeless and substance-use epidemics as a healthcare and social issue, not a legal nuisance. This creates points of contact for lifesaving intervention, healthcare delivery, social support, and structural harm-reduction education for people in need and those who can help during this humanitarian crisis.