DOMICILE UNKNOWN Review of deaths among people experiencing homelessness in Multnomah County in 2015 The numbers in this report are staggering. Eighty-eight people died while experiencing homelessness last year and at least 279 people have died since we began this annual count in 2011. As a County Commissioner, and now Chair, I have studied every policy and option to get people off the street and into safe, affordable housing. The current housing crisis has its roots in decades of deep federal cuts that have been amplified by the recession and an opiate epidemic that sweeps healthy people into addiction. Multnomah County must respond to all of that. We must continue to expand our emergency shelters so that more people can find safety off the streets. We must increase the number of affordable housing options so people can find permanent, stable housing. We must do it for the women I met around my mother’s breakfast table, who were fleeing violent partners. We must do it for the middle school students I met doing their homework as they lined up for the family shelter last winter. And, we must do it for the 88 people remembered here, in this report. Imagine being homeless, you are cold, you are wet. Your mind is racing. Where will you sleep tonight? Will you be safe? Will you be assaulted? Worse yet, will you be sexually assaulted? It’s hard to concentrate, your entire body is tense, you have sleep deprivation. You are told that you are number 522 on a waitlist for housing at the local shelter. As the director of Street Roots, I meet with people experiencing the hell that is homelessness everyday. Even as I write about it, and work to change it, the annual Domicile Unknown report always pulls me up short. Eighty-eight people died on our streets, more than 279 individuals over the past five years. That is a wake-up call for our community. We must do all that we can possibly do to create more affordable housing, mental health and addictions services. There is simply no reason that, in a community that is thriving economically, that hundreds of people should be dying on our streets, isolated and alone, and without a safe place to call home. It is beyond tragic. We must work harder. Each death is a tear in the fabric of our community, it rips through us, and touches all of us. None of us should rest as long people are dying on our streets. Israel Bayer, Executive Director, Street Roots Deborah Kafoury, Multnomah County Chair This report is dedicated to those who died and their families Two degrees and a job Christopher Adams held two degrees from Oregon State University. He had a job and a family who loved him when he died April 19, 2015 in a Portland storage unit. Christopher was born so sight-impaired he could never drive. He applied for Social Security disability but was denied. His poor vision sometimes made him appear awkward so that, despite his education, he was passed over for dozens of jobs. The rejection was painful. When he began talking to himself in his late 30s, his sister drove him to a walk-in clinic where he was diagnosed with schizophrenia and bipolar disorder. There was no supportive mental health services available and he resisted getting help. Still, he functioned, getting a job at KMart, a gym membership so he could go to work freshly showered, and a storage unit, where he apparently stayed. His sister had been driving around looking for him – unaware he was seriously ill – when he died. “People say there are all these services,” his sister said. “But we went down every avenue and nobody helped. I want people to know someone’s life ended this way.’’ He was the smartest person I ever knew. But he died of a perforated ulcer – something “that can be treated and fixed – in a storage unit. He’d been working just two days earlier. He never missed a shift. ’’ – Christopher’s sister 4 Introduction of deaths among people experiencing homelessness. The Multnomah County Health Department’s annual review of homeless deaths finds that 88 people who were experiencing homelessness died on local streets in 2015. Since Multnomah County first began tracking deaths in 2011, at least 279 people have died. The purpose of this analysis is to determine the number, characteristics and causes of homeless deaths in Multnomah County. The Domicile Unknown report is intended to help the public, elected officials and social service providers identify where resources and policies can be directed to save lives. It is also a sobering reminder of the devastating impact of homelessness on human health. What the report captures The Oregon State Medical Examiner and the Multnomah County Medical Examiner’s Office are responsible for investigating all suspicious or unattended deaths, including violent or accidental deaths or overdoses. The Medical Examiner investigated 2,200 cases of death between Jan. 1, 2015 and Dec. 31, 2015. Of those, investigations revealed 88 people to have been homeless at the time of death. Key Findings More people died while experiencing homelessness in 2015 than in each of the previous four years. Since the review began, 88 people died in 2015, 56 people died in 2014; 32 people died in 2013; 56 people died in 2012 and 47 people died in 2011. In 2015, as in each of the previous years, most of the people who died were men. The youngest man was 17 years old, the oldest was 78. Seventeen women died in 2015, a sharp increase from four female deaths in 2014. The youngest woman to die in 2015 was 22 years old, the oldest 68. Overall, women died younger than men, with a mean age of 41, versus 50 for men. Number of deaths Ten African Americans/Blacks also died in 2015, up Since 2011, the Health Department has worked with from seven deaths the previous year. the Multnomah County Medical Examiner’s More than half of the 88 deaths were accidental, and Office to review cases of deaths in which people a quarter were from natural causes. Five people died were likely homeless. The methodology has reof homicide, up from one homicide in 2014. mained the same since it was developed. It does not capture all Alcohol or drugs deaths among caused, or conNumber of Homeless Multnomah County people who were tributed, to Medical Examiner Cases, 2011-2015 homeless, such death for 44 peoas those who ple, with heroin 100 died in a hospital or prescription 90 of natural causes. opiates playing 80 As a result, it is a role in 22 of 70 almost certainly those. an undercount of 60 the total number 50 40 30 20 10 0 2011 2012 2013 Overall trend: mean increase of 16% per year between 2011 and 2015 (range 7% to 26%) 5 2014 2015 A caring counselor’s life derails over pain medication Ryan Cowger was a 4.0 student who found his calling counseling young men with disabilities in Fresno. In his late 20s, Ryan developed kidney stones. To ease the pain of passing them, the doctor prescribed 90 pills of oxycodone. The opiates seemed to flip a switch. “Within months, Ryan was buying pain pills on the street,’’ said his mother. “We went downhill from there.’’ short months, she found the mothers of three others who had died of overdoses. Now Janice and the other mothers are working on legislation to expand access to the opiate reversal drug, naloxone. On Aug. 12, what would have been Ryan’s 33rd birthday, the family scattered his ashes at sea near Pismo Beach “his favorite place in the world.” It was a perfect day, with sightings of seals, dolphins and whales. Then Janice went back to work on naloxone and other strategies to save lives. “I don’t want Ryan’s death to be in vain,’’ she said. Ryan knew he was in trouble, seeking treatment without even telling the family. He underwent two years in rehab and was clean when he decided to move to Portland to start over. He’d been in Multnomah County about a year, and was in transitional housing waiting for an apartment to open up, when in December, 2014, he underwent another minor surgery. Again, doctors prescribed opiates. On Jan. 13, 2015, staff found him in the shower at the transitional shelter. He had overdosed on heroin. He was 32. Back home in Fresno, Janice Paulson never tried to hide that opiates caused her son’s death. She talked about it at work and in her personal life. Within a few “ He was very caring, a kind soul. He was a beautiful young man, ’’ –Janice Paulson, Ryan’s mother. 6 Methods Data Analysis Data Source Case information for all deaths in Multnomah County during 2015 was abstracted from the Medical Examiner database. Ninety-five cases were coded ‘domicile unknown,’ with 78 cases (81%) flagged for further review and 17 (18%) cases classified as homeless. Upon review of death narrative reports, supplemental information, and address records for these 78 cases, 71 (91%) met the Housing and Urban Development definition of homeless. In the remaining 7 cases there was either inadequate information available to make a retrospective determination of homeless status, or there was information indicating that the decedent had a permanent residence. This analysis is limited to the 88 (71 + 17) cases in which the investigation indicated the individual was experiencing homelessness at the time of death. The Oregon State Medical Examiner maintains a database of all deaths investigated under its jurisdiction. In December 2010, the data field domicile unknown was added to the database for Multnomah County so that deaths of individuals who may have been homeless at the time of their death could be easily extracted. Death investigators make multiple attempts to identify a place of residence for decedents through scene investigation and interviews with relatives and social contacts. According to ORS 146.090 the Medical Examiner investigates and certifies the cause and manner of all human deaths that are: (a) Apparently homicidal, suicidal or occurring under suspicious or unknown circumstances; (b) Resulting from the unlawful use of controlled substances or the use or abuse of chemicals or toxic agents; (c) Occurring while incarcerated in any jail, correction facility or in police custody; (d) Apparently accidental or following an injury; (e) By disease, injury or toxic agent during or arising from employment; (f ) While not under the care of a physician during the period immediately previous to death; (g) Related to disease which might constitute a threat to the public health; or (h) In which a human body apparently has been disposed of in an offensive manner. For the period January 1, 2015 through December 31, 2015, we extracted from the database the date of death, sex, race, age, cause, and manner of death for records in which the individual’s address was noted to be ‘domicile unknown’ or ‘transient.’ 7 To protect the privacy of decedents, demographic data were suppressed if cell counts were below three. Low counts for manner of death were not suppressed because this information is publicly available from the Oregon Health Authority. Because of the limitations of using Medical Examiner data for this report, we compiled only the frequencies of each variable and did not attempt to analyze differences in this group of homeless decedents to any other group, or to estimate specific rates. Frequencies were compiled using SAS 9.3. For the season of death, the year was divided into October-March and April-September. Results Cause and Manner of Death Age, Sex, Race The Medical Examiner database includes information on the cause and manner of death. The manner of death is classified as natural, accident, suicide, homicide, or undetermined. Natural deaths are usually medical conditions, while the most common causes of accidental deaths are trauma and intoxication. Of the 88 decedents, 71 were male; the mean age at death for males was 50 years. The 17 females who died had an average age of 41 years. Although race and ethnicity was not established in all cases, the majority of decedents were classified as White/Caucasian (n=68), followed by African American/Black (n=10) and Hispanic (n=3). Other racial or ethnic categories accounted for fewer than 3 deaths each. Racial information was missing for 6 of the deaths. Table 1 Demographics, Homeless Multnomah County Medical Examiner Cases, 2015 Sex Number Mean Age (range) Male 71 50 (17-78) Female 17 41 (22-68) TOTAL 88 48 (17-78) Race* White Number 69 African-American/Black 10 Hispanic 3 *Note: Values may not add up to total due to missing data and low counts. Season Because people experiencing homelessness are often exposed to the environment without shelter, we looked at the frequency of deaths during cooler (October-March) and warmer (April-September) periods of the year. In 2015, around half the deaths (49%) occurred between April and September, while 51% occurred during the colder months of October-March. Table 2 Season of Death among Homeless Multnomah County Medical Examiner Cases, 2015 Season Number (%) April - September 43 (49%) October - March 45 (51%) 8 Of the 88 individuals who died experiencing homelessness in 2015, 47 were accidental deaths, 21 were natural deaths, and 20 were homicide, suicide, or undetermined manner. Among the accidental deaths, 67% were related to drug or alcohol consumption, while the remaining individuals died of a variety of causes including drowning and trauma. For the 21 natural deaths, causes included alcohol-related liver disease, atherosclerotic heart disease, peritonitis, chronic obstructive pulmonary disease, and unspecified natural disease. Ten deaths in total were attributed to suicide and homicide, while 10 had an undetermined manner. Causes of death for these undetermined manner included drowning, trauma, and overdose. Table 3 Manner of Death among Homeless Medical Examiner Cases, Multnomah County, 2015 Manner of Death Number (%) Accident 47 (53%) Natural 21 (24%) Undetermined 10 (11%) Homicide 5 (6%) Suicide 5 (6%) TOTAL 88 (100%) Toxicology Location In 44 (50%) of the 88 deaths, drug or alcohol toxicity either caused or contributed to death. Some deaths were associated with more than one substance, and opioids (heroin and prescription) were noted in 22/44 (50%) individuals for whom drug or alcohol toxicity caused or contributed to death, or one-quarter of all deaths. Over half of homeless decedents were found in outdoor public spaces, followed by indoor public spaces (Table 5). Table 4 Figure 1 shows the location of homeless deaths by location of deceased. For individuals who died in hospitals, the location is the ZIP code of the hospital. Deaths are geographically distributed across the county. Deaths Involving Substances as Contributing or Primary Causes of Death, 2015 Table 5 Substance Number (N=88) No substance 44 Any substance 44 Any opiate (heroin, prescriptions, or unspecified opiates) 22 Any heroin 19 Any prescription opiate 3 Any methamphetamine 13 Any alcohol 17 Any cocaine 4 Note: Deaths involving more than one substance fall under more than one category. 9 Location of Death among Homeless Multnomah County Medical Examiner Cases, 2015 Location Number (%) Outdoor public 46 (52%) Indoor public 19 (22%) River 9 (10%) Hotel/Motel/Shelter 7 (8%) Hospital/corrections 7 (8%)* TOTAL 88 (100%) Note: Manners of death for hospital/corrections: 4 accidental, 2 natural, 1 homicide. No deaths in corrections were due to homicide or suicide. Figure 1. Multnomah County ME Domicile Unknown Cases by Location (ZIP) of Death, 2015 Multnomah County Medical Examiner Domicile Unknown Deaths in 2015 by ZIP* (N=88) E Hospitals Deaths 1-2 97203 3-4 97217 5-6 97211 7-9 97218 No data 97220 97210 97227 E Legacy Emanuel 97209 97204 97205 97201 E 97230 97212 97232 E Providence Portland 97214 97216 Oregon Health & Science University E 97060 Adventist Medical Center 97233 E Legacy Mount Hood 97019 97030 97239 97202 97206 97266 97236 97080 97219 97222 0 *ZIP refers to location of body, unless death occurred in a hospital (n=6) 10 1 2 4 Miles ¯ Comparison to previous years Since 2011, medical examiner deaths occurring in homeless individuals have been increasing, although the data show some variability. The year 2013 had the lowest count during the previous five years (32 deaths), and 2015 had the highest (88 deaths). The overall proportion of ME-investigated cases that are in homeless individuals has also varied over time, ranging from 3.4% in 2013 to 8.7% in 2015 (Figure 2). Figure 2. Percent of Multnomah County ME deaths that are domicile unknown, 2011-2015 Homeless deaths as a percentage of total Medical Examiner Cases, Multnomah County, 2011-2015 percentage of ME deaths 10 8.7 9 8 7 6 5 6.2 6.3 5.1 4 3.4 3 2 1 0 2011 2012 2013 2014 2015 New challenges demand new strategies Each of the 88 people who died in 2015 had a life story that, through tragic circumstances, ended on the street. Many of the deaths were preventable; others were decades premature. For most, access to housing, mental and physical health care and substance abuse services would have likely made a difference. It is also likely that some lives could have been saved earlier through investments in schools, mentorships, employment training and other supports that create stability and security in a person’s life. These individuals may have had some strong relationships. They may have had a shelter to stay in, they may have died of old age. But none of them should have died without a home. We can do better. 11 Our community faces a growing gap between rental costs and what people can afford. Federal spending on housing assistance nationwide has fallen 30 percent since 1996. Population growth in the Portland metro area and stagnant wages have placed much of the housing supply out of reach for many people. Despite the expansion of health care coverage, for many, access to mental health and treatment remains a challenge. Major life crises such as domestic violence, depression and physical disability too often are enough to push people onto the street. Amid these challenges, Multnomah County is working with the cities of Gresham and Portland, and with the faith, nonprofit, business and philanthropic communities to address homelessness and the housing crisis through an initiative called A Home For Everyone. The partners working on A Home for Everyone have established goals for fiscal year 2017: First, we are investing in prevention. Our goal is to keep 5,000 people from becoming homeless through a combination of rental assistance, benefits recovery, legal assistance, and employment programs. Second, we are working to move over 4,350 people into housing by expanding placement services. Third, we are working to make shelter available to an additional 2,000 people a year by adding 650 new year-round shelter beds. Multnomah County and the City of Portland added $17 million to these efforts. Our total investment is now $43 million. And we are working to become more efficient. We recently consolidated homeless services into a new joint city/county office, housed at Multnomah County. Previously, the city of Portland was responsible for helping single adults, while the county was responsible for families. Now anyone who needs help is served by one entity. A mother who is looking for a safe, dry place for her child to sleep at night doesn’t care which government is supposed to help her – she just needs help. Even with this unprecedented community effort, people are still dying on our streets. This is unacceptable. We need to build on our work and push ourselves harder. For too many of our neighbors, it is literally a matter of life or death. To address this challenge, the Multnomah County Chair developed these strategic investment and policy recommendations in consultation with the Board of Commissioners, Health Department staff, Street Roots, A Home for Everyone and housing partners. Recommendations going forward ization. Transitional housing is a bridge from homelessness to a stable temporary living situation for up to a year. There, the person can develops a good tenant history and skills to maintain their own residence on their way to permanent housing. •• Build upon Mental Health First Aid programs that reduce stigma and encourage families and individuals to seek care that is needed. Multnomah, Clackamas and Washington Counties currently offer free classes to anyone over 18 on how to respond to someone in a mental health crisis. The courses, available at www.gettrainedtohelp.com help community members identify or understand anyone having a crisis. It directs people how to act-- based on the evidence -- to help keep the affected person safe and to take steps toward recovery. Educating more people in our community about mental illness also helps reduce stigma and helps everyone know where to get help. •• Increase availability of peer services, access to individuals with lived experience and other natural supports for families and individuals recovering from illness. Unlike many professional counselors, peers have experienced substance use and mental health issues firsthand. Peers support a person in need emotionally, share knowledge, provide concrete assistance, and create a community to support recovery from mental illness and substance use. To reduce deaths on the street overall: •• Increase the number of affordable housing units. More Multnomah County residents are being evicted or priced out of their homes. We must support strategies to prevent evictions. We must develop new apartments and homes that are affordable across incomes. In particular, we must develop more housing for people living at less than 30 percent of median income, which in the Portland metro region is $15,400 for a single person and $22,000 for a household of four. •• Continue to invest in supportive services and rent assistance to help people obtain and retain permanent housing. In particular, for people with disabilities, we must provide the financial assistance and wrap-around services critical for a person returning to, and remaining in, permanent housing. •• Provide emergency night and day shelter to those who cannot find permanent housing. Emergency shelter offers basic safety off the streets and reduces exposure to inclement weather, violence, stress, physical illness, hunger and other threats that people experiencing homelessness face. To reduce the number of accidental deaths and suicide: •• 12 Support a continuum of housing resources for individuals with behavioral health issues including shelter, recuperative care, transitional supported housing and permanent supported housing. Recuperative housing is for someone who cannot care for one’s self following a behavioral health crisis/hospital- To reduce deaths associated with overdose: •• Continue prescribing guidelines that standardize opiate prescribing practices, provide alternative treatments for pain and support recovery. Continue implementing evidence-based opiate prescribing guidelines into clinical practice. Support the Tri-County Regional Opioid Safety Coalition’s work on expanding these practices, increasing safe disposal and naloxone distribution sites. •• Create access to high-quality addiction treatment, including medically assisted treatment. Nearly one quarter of deaths documented in Domicile Unknown included opioids as a contributing factor. As a community, we can work to expand the number of qualified providers who approach addiction as a treatable condition. 13 •• Enhance and expand the levels of care available in substance use treatment. There needs to be a continuum of support for people with substance abuse issues. Residential beds should be preserved for those who need that level of support. Others can benefit from housing with an on-site professional peer mentor with intensive outpatient services. Other important supports including peers, people with lived experience, and natural supports such as Narcotics Anonymous, also help people be successful while staying in the community. •• Improve access to naloxone, needle exchange, opiate disposal and increased outreach. Community-based distribution of naloxone is effective in reversing overdoses. Safe disposal of used syringes and unsued drugs reduces harm. Increased outreach often includes referrals to health insurance enrollment, health care and other services. Explore pursuing additional strategies, including expanded wound care health services and evaluating the feasibility of a supervised injection site. A death by addiction “doesn’t hurt any less” from California, Texas, Oklahoma, in and out of jail for nonviolent crimes to support his habit. At 33, he disclosed he’d been sexually abused while in the care of childhood babysitters. But he was happy in Portland. He loved the Pacific Northwest, its politics, music and people. He moved in and out of housing, moved in and out with friends, but he stayed connected to Katy. He flew home to bury their father. Three months later, he stopped answering his phone. Katy is haunted that his addiction robbed him of his future and of their cherished past. Almost no one attended his services. Looking back, Katy Rogowicz sensed that August night that something terrible had happened to her brother, Michael Kenneweg. The two had grown up in Michigan, close enough to be mistaken as twins. She’d been talking to him almost everyday when he abruptly stopped picking up in Portland. Later that day, deputies brought the news to Katy’s Michigan home. Michael had died of a heroin overdose in a restaurant bathroom in Portland. “I lost my brother and my sibling and with him, all those little things we used to have, our secrets,’’’ she said. “We used to make up songs, we could get each other to laugh without saying a word. Now my childhood is like a shadow over it. Instead of looking back and enjoying it, it looks fake. I didn’t know how sad and tragically my brother’s life would end.’’ The married mother of two has spent years trying to understand how her brother slipped from their middle class upbringing into addiction. He moved saw Mike die slowly over a decade. “ We It was no different than someone who died of cancer. It doesn’t hurt any less. The loss is the loss. ’’ –Katy Rogowicz, sister 14 “People don’t have compassion when someone dies of a heroin addiction,’’ she said. “That’s what makes it so much more painful. It doesn’t change the fact he was my brother, he had people who loved him. He was my favorite person in the world.” Acknowledgments Authors of Methods and Results Jaime K. Walters, MPH Senior Epidemiology Research Associate, Community Epidemiology Services Multnomah County Health Department Amy Zlot, MPH Senior Epidemiologist, Community Health Services Multnomah County Health Department Paul Lewis, MD, MPH Health Officer, Multnomah County TriCounty Health Officer, Clackamas, Multnomah and Washington Counties Investigators Karen Gunson, MD, Oregon State Medical Examiner, Multnomah County Medical Examiner Kimberly DiLeo, Chief Deputy Medical Examiner, Multnomah County Erin Patrick, Lead Deputy Medical Examiner, Multnomah County Patrick Chamberlain, Deputy Medical Examiner, Multnomah County Peter Bellant, Deputy Medical Examiner, Multnomah County Thomas Chappelle, Deputy Medical Examiner, Multnomah County Damon O’Brien, Deputy Medical Examiner, Multnomah County Lindsay FitzSimmons, Deputy Medical Examiner, Multnomah County Shana Aivaliotis, senior office assistant Multnomah County Published in Cooperation with Multnomah County Health Department Street Roots Community Newspaper Supported By Multnomah County Chair Deborah Kafoury Oregon State Medical Examiner Multnomah County Medical Examiner’s Office Contact Julie Sullivan-Springhetti Multnomah County Communications Office julie.sullivanspringhetti@multco.us (503) 709-9858