Understanding the Impact of Structural Racism and Violence Across the Lifespan on Overdose Vulnerability Among Black San Franciscans Experiencing Homelessness

Overdose in California is highly racialized, with Black Californians experiencing excessive mortality. People experiencing homelessness (PEH) report high rates of fentanyl-stimulant co-use and drug-related harm. There is limited research examining structural racism and intersectional violence of policing, homelessness, and overdose throughout the lifespan of Black people. POLY HOME is a qualitative study among PEH who fentanyl and stimulants in San Francisco, California, examining how housing status shapes drug-related harm and engagement with overdose prevention, services, and treatment. We analyzed baseline and life history interviews from 26 Black participants. They reported experiences of physical and psychological violence and associated trauma resulting from the criminal legal system during childhood, adolescence, and adulthood. Black participants reported viewing the police less as a community resource than as a form of potential community harm, leading participants to avoid emergency services and law enforcement during life-threatening events. Increased policing and involuntary displacements increased overdose risk. Our findings elucidate how systemic issues in policing and the criminal legal system contribute to overdose risk among Black PEH. Programs and policies are needed that reduce criminal legal involvement for Black PEH and address how experiences of structural racism across the lifespan impact overdose vulnerability in later life.