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Social Determinants of the Opioid Epidemic
“Now, more than at any other time in our history, the addict is a product of a society which has moved faster and further than it has allowed him to go, a society which in its complexity and its increasing material comfort has left him behind. In taking up the use of drugs the addict is merely exhibiting the outermost aspects of a deep-seated alienation from this society, of a combination of personal problems having both psychological and sociological aspects.”
“The fact that addiction is bound up with the hard core of the worst problems confronting us socially makes it discouraging at the outset to talk about solving’ it. Solving’ it really means solving poverty and broken homes, racial discrimination and inadequate education, slums and unemployment….”
Senator Robert Kennedy
Social determinants such as poor housing conditions are often accompanied by neighborhood-level conditions that limit access to health care, risk-reduction information, and treatment alternatives, which are protective resources and can disrupt behaviors that ultimately lead to opioid addiction.
Economic hardship and high rates of unemployment consistently characterize vastly different communities hit hard by the opioid crisis such as Appalachia and urban centers in the United States, as well as Russian communities dislocated by the Soviet Union’s economic collapse, plausibly shows that social determinants contribute to hopelessness and social trauma that “set the stage” for opioid abuse and dependency. Leading social scientists understand that social factors play a key role in directly and indirectly determining the incidence and prevalence of addiction disease. The reasons, however, are not yet well understood. Some researchers suggest that low educational attainment, income, and employment success produces poor social networks, low levels of power, prestige and self-mastery that contribute to illicit drug use. Also, social conditions such as homelessness or high exposure to violence can shape health behaviors by increasing opportunities and perceived reasons for engaging in high risk behavior. Social determinants such as poor housing conditions are often accompanied by neighborhood-level conditions that limit access to health care, risk-reduction information, and treatment alternatives, which are protective resources and can disrupt behaviors that ultimately lead to opioid addiction.
Patients in pain deserve compassionate care just like any other patient physicians treat, and stigmatizing patients who require opioid therapy is often a barrier to optimal treatment. In medicine, we do not use terms such as “malingerer” or “drug seeker” because these terms carry with them damaging psychological stigma. Patients who need care are simply “patients,” and we should seek to change the tone of the debate toward more attention on multidisciplinary, patient-centered approaches to pain management and ensuring that evidence-based alternative pain management treatments and strategies are covered by insurance while supporting opioid-based therapies when clinically appropriate and effective.
The impact of housing on health is now being widely considered by policymakers. Housing is one of the best-researched social determinants of health, and selected housing interventions for low-income people have been found to improve health outcomes and decrease health care costs. As a result, many health care systems, payers, and government entities are seeking to better understand the totality of the health and housing literature to determine where they might intervene effectively. This brief outlines the literature and provides high-level direction for future research and policy agendas.
New research indicates that an increase in minimum wages can have important health benefits—a finding that is relevant to public debates about both health and economic policy.
Criminal Justice (Public Safety)
Food and Nutrition
Epidemiological research suggests that nutrient imbalance is a strong predictor of substance use and may be partially mediated by depression. Some authors have recommended dietary supplements for use in early recovery from heroin. It remains unknown how these supplements interact with MAT, and the reader is referred to a more comprehensive review. Methadone maintenance patients have received nutritional counseling aimed at reducing diet-related morbidity but a lack of measurable changes (e.g., weight) reduces the scientific salience. Meanwhile, nutrition services provided within the Veterans Affairs health care system have been associated with significant improvements in treatment outcomes. Learn More
Positive incentives to promote physician education and public awareness, useful tools that physicians can use at the point of care to support medical decision-making, concerted attention to increasing access to quality addiction treatment.
Individuals can rate their experience with their physicians associated with an attitude of the health care system and providers. (The challenge of rating)
Avoid the use of terms such as “malingerer” or “drug seeker” because these terms carry with them damaging psychological stigma. Patients who need care are simply “patients,”
Establish a bill of rights for individuals suffering from pain or opioid-related challenges
Montgomery County or other local settings should create a comprehensive day-long symposium aimed at public education around overdose awareness. This symposium should offer different tracks, including healthcare professionals, educators, family and friends of those in recovery, law enforcement, among others.
We can challenge the media, entertainment, and other social organizations that may have a negative approach.
The media’s stories about how the opioid crisis cuts short promising lives are renewing public attention, commitment, and concern.
Viewing substance use disorders as a chronic disease that waxes and wanes, not as a moral failing, may help overcome stigma that prevents affected people from seeking treatment.
Encouraging public dialogue that refers to a “person with a substance use disorder” (instead of “addict”) and “person in recovery” (instead of “former addict”) can medicalize what many still view as primarily a criminal problem.
The key to a successful battle against opioid addiction will be prioritizing interventions aimed squarely at environmental risk factors in order to address the true impacts that social determinants have on opioid-dependent populations, while also continuing efforts begun to address prevention and treatment aimed at the supply side and continuum of care.
A deadly crisis: mapping the spread of America's drug overdose epidemic
By Nadja Popovich
Overdoses kill more Americans than car crashes or guns – and experts say the crisis hasn’t yet peaked. Data reveals how a local problem became a national epidemic
Ecosystem and Stakeholders
Why the “Disease Model” Fails to Convince Americans That Addiction Is a Health Issue
Recovery Bill of Rights
The National Neighborhood Indicators Partnership (NNIP) is a collaboration between the Urban Institute and local organizations that connect people with neighborhood data. We tackle challenges in education, health, housing, economic opportunity, and public safety. The NNIP Model, the partnership, and work in conjunction with affiliated organizations are described below.
Recommendations That Address Social and Environmental Risk Factors Contributing to America's Opioid Epidemic
Utilize Medicaid to reimburse supportive housing programs that co-locate employment, education, and health services
Promote and finance two-generation, family centered treatment and support for children under foster and kinship care
Involve community leaders in designing preventive systems for younger children to promote healthy behaviors, social skills, community opportunities, and pro-social involvement
Broaden public health-based approaches to rebuild workforce capacity among victims of past drug epidemics
Extend the benefits of public health-based interventions to individuals who were burdened by criminal justice rather than public health approaches to the disease of addiction during America’s earlier opioid crisis
Strengthen supports for public housing providers to avoid eviction when residents are amenable to treatment for opioid addiction