The Social Determinants of Addiction

By | February 15, 2018
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Opioid use is a serious concern that the executive branch of the United States government recently declared a public health emergency. Based on data from the Department of Health and Human Services, in 2016, 2.1 million people misused prescription opioids for the first time, and 42,249 people died from overdosing on opioids. Also in 2016, 170,000 people used heroin for the first time, and 15,469 people died from overdosing on heroin. Opioid use in 2016 resulted in $504 billion in economic costs.

Research regarding the social determinants of health, according to Healthy People 2020, suggests that health is determined by “access to social and economic opportunities; the resources and supports available in our homes, neighborhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships.” Though we have this information about the ten primary social determinants of health, it has not particularly been applied to the opioid epidemic in the United States.

Spooner and Hetherington from the National Drug and Alcohol Research Centre of the University of New South Wales [PDF] describe the complex relationship between lower socioeconomic status and propensity for drug use. They also explain the effects of the physical environment and how these effects may serve as risk factors for drug use and addiction.

For example, poor housing quality and overcrowding may lead to depression and noise levels that affect children’s academic attainment. Poor neighborhoods may expose residents to increased crime risk and drug activity—or, in some cases, different social norms around education, employment, crime, and drug use.

Isolation in rural or poor communities, along with decreased access to resources, can result in boredom and unemployment, which Spooner and Hetherington note as risk factors for drug use. Lack of public spaces in which young people can socialize in the presence of adults may result in increased exposure to drug activity, as well as decreased informal social controls from positive adult role models. Spooner and Hetherington conclude that “housing, urban planning, and transport are likely to affect the environment in a manner that promotes or prevents drug-use problems.”

Little is known about the impact of sexual, gender-based, and intimate partner violence on drug use and addiction. However, much of the research on gender-based violence describes substance use as a coping mechanism for the trauma experienced. Recently, Ravi and colleagues published a Medical Care article noting that sex-trafficked women tended to use substances as a primary coping mechanism for trauma-related experiences. Furthermore, sex-trafficked women in the study noted that they often used substances for trafficking-related stress as well, “including using cocaine for the purposes of staying awake for multiple days to meet [financial] quotas, and heroin to numb physical pain during sexual encounters.”

Risk factors for addiction are complex and often related to broader, population-level forces. The social determinants of addiction should be specifically addressed by community, state, and national-level programs and policies.

Rebekah Rollston

Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Instructor in Medicine at Harvard Medical School, Faculty of the Massachusetts General Hospital Rural Health Leadership Fellowship (in partnership with the Indian Health Service Rosebud Hospital), Editor-in-Chief of the Harvard Medical School Primary Care Review, and Head of Research at Bicycle Health, a digital health startup that provides biopsychosocial treatment of opioid use disorder via telehealth. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine (in the Rural Primary Care Track) and her Master of Public Health (MPH) from The George Washington University Milken Institute School of Public Health. Dr. Rollston’s professional interests focus on social determinants of health & health equity, gender-based violence, sexual & reproductive health, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.
Category: Epidemiology Health behaviors Health policy Mental health Prescription medications Primary care Public health Tags: , ,

About Rebekah Rollston

Rebekah L. Rollston, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Instructor in Medicine at Harvard Medical School, Faculty of the Massachusetts General Hospital Rural Health Leadership Fellowship (in partnership with the Indian Health Service Rosebud Hospital), Editor-in-Chief of the Harvard Medical School Primary Care Review, and Head of Research at Bicycle Health, a digital health startup that provides biopsychosocial treatment of opioid use disorder via telehealth. She earned her Medical Degree from East Tennessee State University Quillen College of Medicine (in the Rural Primary Care Track) and her Master of Public Health (MPH) from The George Washington University Milken Institute School of Public Health. Dr. Rollston’s professional interests focus on social determinants of health & health equity, gender-based violence, sexual & reproductive health, addiction medicine, rural health, homelessness & supportive housing, and immigrant health.