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

Abstract

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.

Introduction

With the ongoing “fourth wave” of the overdose crisis in the United States (U.S.) characterized by increasing polydrug use involving fentanyl alongside stimulants, the narrative still largely centers white communities, ignoring the profound racial disparities in overdose mortality (Ciccarone 2021; Friedman, Beletsky, and Jordan 2022). Since 2015, overdose death rates among Black communities have increased substantially (Friedman and Hansen 2022). While overdose rates declined among white people in 2023, they rose significantly among Black people (Garnett and Miniño 2024). Data reveals significant sex disparities in overdose mortality rates, with Black men experiencing the highest rates and an increasingly disproportionate burden compared to their white counterparts (Cadet, Smith, and Martins 2025).

Since the War on Drugs was launched under Presidents Nixon and Reagan in the 1970s and 1980s, policies have prioritized criminal legal system initiatives over public health initiatives for drug use, targeting marginalized communities, particularly Black communities (James and Jordan 2018). These policies emphasized police militarization and mass incarceration, reinforcing stigmatization and the criminalization of people who use drugs (PWUD). The War on Drugs reinforced ongoing structural anti-Black racism, founded on colonization and chattel slavery, which continues to produce violence, trauma, poor health outcomes, and mass incarceration, framing Black people as inhuman or “other” (Andrasik et al. 2022; Hansen, Netherland, and Herzberg 2023).

Black people are more likely to experience police violence, surveillance, and criminalization than their white counterparts (Alexander 2020; Andrasik et al. 2022). Historical and ongoing housing and economic discrimination; through redlining, gentrification, and inequities in education and employment have contributed to rising overdose mortality rates in Black communities (Fowle 2022; Kunins 2020; Lindenfeld et al. 2024). Black people are disproportionately affected by fatal overdoses and more likely to be killed by law enforcement (Doe-Simkins, El-Sabawi, and Carroll 2022; Zhu 2024). Post-incarceration, the risk of fatal overdose increases significantly, placing Black people newly released from jail or prison at elevated risk (Mital, Wolff, and Carroll 2020; Zhang et al. 2022). While Black men remain at the highest risk of incarceration, the rate of incarceration for Black women has doubled compared to white women over the past three decades (Alexander 2020).

Black people in the criminal legal system are further at a heightened risk of overdose mortality, as people often lose access to essential social services, education, housing, and employment. This systemic exclusion is reflected in the ongoing rise in homelessness across California. Although Black people make up only 7% of the state’s population, they represent 26% of those experiencing homelessness and face a significantly higher likelihood of incarceration compared to other racial groups (Young Ponder et al. 2024). Mass incarceration, what Patricia Hill Collins (2023) refers to as a form of intersectional violence, is a tool of political domination used to maintain power and social inequality. Intersectionality explains how multiple systems of power such as racism, sexism, capitalism, and nationalism, join to produce and maintain violence, disproportionately affecting Black communities (Collins 2023). Lethal intersections occur where these overlapping systems result in death or vulnerability to death, as seen in the ongoing racialized disparities of the opioid overdose crisis (Collins 2023; Friedman, Beletsky, and Jordan 2022; James and Jordan 2018).

Structural racism continues to drive racialized disparities in homelessness, fatal drug overdoses, and criminalization, reinforcing longstanding racial injustices (Castellanos et al. 2023; Cruz and Jegede 2024; Kunins 2020; Paul et al. 2020). There is limited literature that examines the structural racism and intersectional violence of policing, homelessness, and co-use of opioids and stimulants throughout the lifespan of a community of Black people. This manuscript explores Black people’s experiences with policing across the lifespan and how these interactions shape their vulnerability to opioid-related overdose.

Methods

POLY HOME was a longitudinal qualitative study among PEH who co-use fentanyl and stimulants in San Francisco, California. This study was approved by the Yale University Institutional Review Board, which served as sIRB for the study (#2000035608). All participants completed written informed consent. We recruited and enrolled 66 participants from community-based sites in four neighborhoods of San Francisco. Participants were adults who spoke English or Spanish, were experiencing homelessness, and used both stimulants and fentanyl in the past week. After completing an eligibility screener, we started with a baseline interview using a semi-structured interview guide and conducted a more in-depth life history interview approximately 1 week later. Everyone who completed an eligibility screener received $5 cash regardless of eligibility. Participants received $50 cash for each interview they completed. For this paper, we used the Intersectional Risk Environment Framework (Collins et al. 2019) to analyze baseline and life history interview data from 26 participants who identified as Black, African American, and/or North African to understand the impacts of intersectional violence and racialized trauma across the lifespan on homelessness, drug use and overdose. We collaboratively developed a codebook and met to resolve any coding discrepancies between primary and secondary coders. Qualitative interviews were transcribed verbatim and de-identified. Transcripts were uploaded to Dedoose for coding (2023), after which we completed thematic analysis. Our team utilized a modified Grounded Theory approach to data analysis (Charmaz 2014).

Results

Black participants described how interactions with the criminal legal system and surveillance over their life course intersected with their current experience of homelessness and drug use. These lifelong experiences had an enduring impact on their perceptions about interactions with emergency medical systems and law enforcement. They reported prioritizing and maintaining safer drug use practices, despite the potential risks associated with drug use in public or communal environments.

We identified three themes: (1) youth and adolescent interactions with criminal legal system violence; (2) experiences of discriminatory policing in adulthood while homeless; and (3) perceptions of overdose vulnerability and safety, with subthemes (3a) hesitation to seeking help from emergency services and (3b) community responses to the overdose crisis.

Youth and adolescent interactions with criminal legal system violence

Participants reported racialized and negative interactions with police during youth and adolescence, including racial profiling and unwarranted searches. One participant recalled how her friends learned to adapt to being targeted by police at a young age:

I seen what they’ve done to people. And they used to harass us when was younger, pull us over and go through our car and all that crap. But we wouldn’t even have anything on us. And if we did, we’d get rid of it … They profiled all the time, so you don’t want to be driving around.

Participants emphasized their interactions with police and experiences with incarceration often began at a young age. For example, when asked what interactions he had with the criminal legal system, one participant reported going to jail at 11 years old. Another participant explained how incarceration started at an early age in his community: “Where I’m from, I’m a late bloomer going to jail. I didn’t start going to jail till I was 17.”

Early and repeated exposure to policing and systemic racial targeting led to the internalization of negative stereotypes and normalization of police interactions. Incarceration was described as a regular experience, particularly among young Black boys and teens. One participant shared:

Going to jail in the ghetto environment is like a badge of honor. Everybody talk about it and be curious. You would have conversations people be like man, “I can’t wait to go to the pen.” And now the older you be like, “What are you talking about?”

In some cases, interactions with police included being physically assaulted. One participant recounted an incident in which he was around 10 years old and experienced overt violence from police when his home was being raided.

And I remember sitting on the couch, they [police] even had guns pointed at us at one point. And they end up tearing the house up real bad where we had to stay in a hotel […] they was getting kids too and they grabbed me and popped me across the head and put a gun on me too. I didn’t even know they was police. They had these masks on and stuff. I was screaming for my dad.

Another participant discussed how he had been working as a teenager out of high school but then got arrested for selling marijuana, which derailed his opportunity to play basketball at a major college.

I ended up taking probation on that. That was the beginning of my woes as a young person. I was very young when I went to Santa Rita jail. I should have been going to a youth authority, because I think I was still 17. But I guess because I was close to 18 or whatever, but I didn’t see no young people in there when I went. There were no people my age in Santa Rita at that time […] This is my situation.

This further illustrates how several participants have been treated as adults by the criminal legal system while they were children, as evidenced by this participant being charged and incarcerated as an adult.

Experiences of discriminatory policing in adulthood while homeless

Multiple interactions with police during youth and adolescence led to extensive involvement with the criminal legal system for many participants, which then increased the likelihood for further police interaction into adulthood. One participant described feeling trapped in this cycle:

So they would send me back like if I violated [probation/parole], they would send me [back to jail]. I went back like six times just on violation … It seemed like I couldn’t never get off. [I’m] still on probation. It’s like I kept just getting in trouble. Could never like get that shit behind me.

Participants reflected that these early experiences with police impacted their current mistrust of police. Policing was not viewed as a source of protection, but rather as a tool of community harassment and violence, as one described: “I’m always going to be harassed. I can’t even go to the computer and at the library because the cops that per se guard these, they literally find shit and start shit with me.”

Another participant reflected on the police continuously harassing him and assuming he was on probation, demonstrating his feeling of ongoing surveillance: “The police love my ass, boy … Shit they think I got like probation or something … I’m just staying cool, staying out the way.” Participants recounted their attempts to avoid police encounters in community settings, though these efforts were often ineffective. Within the Black community, there was a shared understanding that it is safest to remain unassuming and knowledgeable about the law to avoid unnecessary interactions with law enforcement.

While experiencing homelessness, these participants discussed the heightened and continuous interactions with the police while communing and living outside. One participant recalled the violent and racially motivated nature of police interactions he had received congregating outside. He described a recent incident where he was the only Black man in a group of peers and an officer asked whether he alone would prefer to be physically assaulted or issued a citation.

I’ve gotten, “do you want a ticket or do you want a punch in the face?” So, I’ll take the sock in the face, hella different shit like that. Or I’ll be the only one that gets a ticket within a group of white people, and then I’ll be the only one that gets a ticket.

Experiences with extensive policing and incarceration throughout adulthood were described as significantly contributing to housing instability and drug use challenges. One participant shared that they received an eviction notice while in jail, at a time when they had intended to stop using drugs. However, after being released and becoming unhoused, they began using drugs again to cope.

Before that I was in jail. So, when I got out, I had 45 days to vacate the premises … I had been in jail for like 57 days. So, when I got out, I had planned to stay clean … So, I was on my own. So, then I wind up just using, because that’s the only way I knew how to cope with it.

After being released from incarceration, participants experienced stress during this transitional process and the lack of stability and support led many to experience unsheltered homelessness. Drug use was used to cope with their situations as it was very stressful to be living outdoors.

During adulthood, participants reported experiencing dehumanization, discriminatory targeting, and violence with police interactions, which significantly increases while experiencing homelessness. Black participants described there was an underlying belief that the police were not ensuring safety but rather were conducting surveillance as a tool of oppressive control.

Perceptions of overdose vulnerability and safety

Participants shared that their drug use has been shaped by experiences of homelessness, which in turn increased their vulnerability to overdose. Contributing factors included greater exposure to drug use when outside, fluctuations in the drug supply, and the use of certain substances, such as stimulants, as a form of self-protection while navigating unsafe environments. The intersection of fentanyl, evolving drug use patterns, housing insecurity, and structural violence, evident in a lifespan history of over-policing, had exposed the Black community to an unprecedented and heightened risk of overdose.

Restrictions to Seeking Help from Emergency Services

Given the awareness of their overdose risk, participants described strategies to stay safe, such as using with others or carrying naloxone, but several also voiced concern about seeking emergency assistance due to fear of police involvement when 911 is called. This apprehension stemmed from fear of the criminal legal system and being treated unfairly by medical professionals. One participant recounted an incident in which she experienced an overdose, and an ambulance was called.

I don’t remember anything else, but people told me I was on the ground. And so, I remember the paramedics came, had me on the stretcher. And they were talking, and it was hard for me to breathe. And they just kept on talking. I’m like, why is it taking so long to take me to the hospital? And they were just talking like it was nonchalant, laughing and all that.

Despite the severity of her condition as she would be admitted to the intensive care unit at the hospital, the medical staff disregarded her needs, engaging in casual conversation and laughter, behaving as though she was invisible.

Another participant described how fear of potential consequences often deters people from calling 911 during overdose events, especially when they are using drugs or engaged in other criminalized activities: “Calling 911. A lot of people are afraid to do that. I tell them it’s okay especially here in San Francisco, you can’t get in trouble for that.” In one case, a participant was in a neighboring city when she administered naloxone to a friend experiencing an overdose. A police officer arrived and advised her to call emergency medical services. However, the situation pivoted when the officer accused her of supplying fentanyl to her friend.

I Narcaned her. She’s fine. I’m just trying to help her up. He [the police officer] says “you need to call an ambulance.” He was like, “What about you? You sure you not the one who give her the fentanyl?” because he hadn’t seen the fentanyl but he had in his mind fentanyl, I’m like, “how you know it was fentanyl? Could be any anything.” He said, “because that’s mostly what people use it [naloxone] for and that’s what you have in your purse. I see the foils.” My purse was wide open … I got fuckin arrested because I had fentanyl possession, fentanyl in my purse.

This incident highlighted the inconsistent application of Good Samaritan Laws, media portrayals of fentanyl, and the assumptions made about PWUD, reflecting the varied experiences individuals have with law enforcement.

Community response to the overdose crisis

In the context of the hesitance and fear of calling 911, the community relied on other strategies to reduce their risk. One participant described their decision to use in the presence of others after experiencing the loss of friends to overdose:

I don’t like to use anywhere by myself. [deep sigh] Because I done found a few of my friends dead, by, you know, locking doors and stuff like that … I try to be aware of other people doing things like that, to keep an eye on them. And always make sure that I’m around somebody and pretty much out in the open.

Participants reported numerous examples of members proactively caring for and protecting themselves and one another. This reflected a strong sense of necessity to ensure safety and well-being, often in the absence of support from structural systems. For example, participants expressed the benefits of communal use as an overdose prevention strategy, even if it was not their preference.

Even though I used to love getting high by myself, it’s not too safe when using fentanyl. So, now I like to keep someone, one or more people around me who may use or may not use. Just someone that’s just there to just make sure that I’m not dead, I’m not dying, I’m not overdosing. That’s a damn safe way [to use] while indulging.

Despite recognizing the benefits of engaging in communal use with peers, some noted that these practices did not fully eliminate the risks associated with using drugs and being unsheltered. One participant shared that using drugs in public spaces, even alongside others, still exposed them to harm or potential victimization: “I got a lot of my stuff stolen. Like nodding out or just falling asleep and wake up with my stuff missing. Drugs or clothes, whatever [is] valuable.” These experiences underlined the importance of stable and safe housing as a foundational element of safety and overdose prevention.

Discussion

This examination of the narratives shared by Black participants reveals how past and present experiences with policing and intersectional violence have contributed to heightened vulnerability to fatal overdoses. Surveillance via discriminatory policing and systemic violence has been enacted upon Black bodies in the U.S. for generations (Benjamin 2019; Edwards, Esposito, and Lee 2018; Weheliye 2014). Researchers and historians have outlined a relationship between the twinned legacies of U.S. police enforcement and slavery to explain the current violence, mistrust, and death that surrounds encounters with police for Black communities (Alexander 2020; Kaba 2020; Kaba and Ritchie 2022; Lamont Hill 2017; Richie 2012). Black participants in our study reported viewing the police less as a community resource than as a form of potential community harm. Literature has identified the common negative sentiments and fear expressed by PWUD toward law enforcement; less attention has been paid to the specific ways in which U.S. racism can structure increased vulnerability for Black PWUD (Banks et al. 2023; Campbell et al. 2025; Doe-Simkins, El-Sabawi, and Carroll 2022; Seo et al. 2025). Research addressing racialized differences in homelessness prevalence and the health outcomes of PWUD, including overdose mortality, must examine the role of structural racism in policy and programming to understand and combat these disparities (Dayton et al. 2020; Jegede, Bellamy, and Jordan 2024; Lopez et al. 2022).

Our findings spanned the life course of participants to elucidate how surveillance and incarceration of Black participants at a young age contributed to increased vulnerability to homelessness and negative police encounters while experiencing homelessness as adults. This bidirectional pattern of vulnerability to homelessness and vulnerability while homeless underscores the impact of structural racism across the life course for low-income Black Americans (Herring, Yarbrough, and Alatorre 2020; Welsh Carroll, Flanigan, and Gutierrez 2023; Young Ponder et al. 2024). Among our participants, cumulative negative experiences with policing contributed to reticence to interact with law enforcement or emergency services in the event of an overdose. Latimore and Bergstein (2017) found similar findings in their study of a majority Black identifying sample, highlighting a deep-rooted hesitancy that deters individuals from seeking help during overdose.

While studies have shown that Good Samaritan Laws can increase the likelihood of PWUD calling 911 during an overdose, mistrust persists, particularly regarding whether these laws are applied equitably to Black people (Jakubowski et al. 2018; Latimore and Bergstein 2017; Pamplin et al. 2023; Seo et al. 2023). Seo et al. (2023) noted that Black participants expressed expectations of being searched or facing punitive responses if naloxone was present, reflecting an intention to avoid police contact due to fears of racialized discrimination and criminalization. Anti-Black racism and structural violence experienced by our participants were not limited to interactions with the criminal legal system. Several participants described a broader pattern of mistreatment and neglect during medical emergencies and care, reflecting systemic disparities in healthcare that disproportionately impacts Black people (Hall et al. 2022). Policing directly influences how people engage with healthcare institutions; individuals who have experienced police brutality are significantly more likely to mistrust the medical system than those who have not (Alang et al. 2021; Dayton et al. 2020).

Research has shown that Black communities are disproportionately affected by the overdose crisis, negative encounters with law enforcement, incarceration, and barriers to medical care, especially among PWUD and PEH (Alang et al. 2021; Cadet, Smith, and Martins 2025; Cano et al. 2024; Dayton et al. 2020; Hall et al. 2022; Rhee and Rosenheck 2021). Racial discrimination contributes to increased susceptibility to homelessness through multiple pathways (Paul et al. 2020). Lifelong exposure to policing, surveillance, and criminalization deeply impacted our participants’ ability to maintain stable housing, safely use drugs, and seek medical assistance in emergencies. Results from this study can guide changes and initiatives to counter anti-Blackness in the U.S. by integrating racial justice into public health practice (Collins 2023). The intersectional risk environment framework reveals how presumably race-neutral policies often allow structurally racist foundations to persist, even in the presence of legislation intended to prohibit racial discrimination (Edwards 2021; Paul et al. 2020). This dynamic is evident in the implementation of Good Samaritan Laws (Doe-Simkins, El-Sabawi, and Carroll 2022). The disproportionate risk of police violence remains a powerful deterrent for Black people who often fear that calling 911 could result in punitive outcomes rather than protection (Doe-Simkins, El-Sabawi, and Carroll 2022; Hall et al. 2025; Latimore and Bergstein 2017; Seo et al. 2023).

To address systemic issues identified in our data, policies should prioritize non-police responses to overdoses, shifting responsibility to specialized medical teams trained in overdose care, harm reduction, and the specific needs of Black PWUD experiencing homelessness (Doe-Simkins, El-Sabawi, and Carroll 2022; Zhang et al. 2022). Resources should be redirected from police budgets toward increasing access to naloxone and expanding community-based overdose prevention programs tailored to the intersectional needs of Black communities (Doe-Simkins, El-Sabawi, and Carroll 2022; James and Jordan 2018; Jordan et al. 2021). Several of our participants described stress and trauma associated with homelessness intensified their drug use as a coping mechanism, thereby increasing their risk of overdose. Addressing this specific vulnerability through stable housing, supported by reforms in both housing and criminal legal system policies, is essential (Paul et al. 2020; Young Ponder et al. 2024). Black PEH, particularly those living outside, face an increased likelihood of encounters with law enforcement, which heightens their exposure to police violence and incarceration (Welsh Carroll, Flanigan, and Gutierrez 2023; Young Ponder et al. 2024). Over the past few decades, homelessness has also become increasingly criminalized, with many city jails functioning as de facto homeless shelters (Herring, Yarbrough, and Alatorre 2020).

Black PEH in our study faced lifelong discriminatory and violent experiences with law enforcement and incarceration that negatively impacted overdose vulnerability. Cyclical experiences with incarceration and the criminal legal system creates significant barriers to employment and housing, compounding both the risk of homelessness and the challenge of exiting it (Paul et al. 2020; Young Ponder et al. 2024). Targeted efforts to support people impacted by the criminal legal system could meaningfully reduce rates of homelessness among Black communities, including: strengthening reentry support for individuals leaving carceral settings, adopting a non-punitive approach to unsheltered homelessness that minimizes police involvement, lowering housing barriers for those with criminal records, and expanding “clean slate” legislation (Bounoua et al. 2024; Paul et al. 2020; Young Ponder et al. 2024). Anti-racist practices must be centered systematically for policies to meaningfully reduce criminal legal involvement for Black PEH and address how experiences of structural racism across the lifespan impact overdose vulnerability in later life.

Data availability statement

Data generated from this study are not publicly available.