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Addressing the Opioid Crisis Means Confronting Socioeconomic Disparities

October 25, 2017

Illustration of a diverse crowd of peopleCreative Commons - Pixabay

The brain adapts and responds to the environments and conditions in which a person lives. When we speak of addiction as a chronic disorder of the brain, it thus includes an understanding that some individuals are more susceptible to drug use and addiction than others, not only because of genetic factors but also because of stress and a host of other environmental and social factors in their lives that have made them more vulnerable.

Opioid addiction is often described as an “equal opportunity” problem that can afflict people from all races and walks of life, but while true enough, this obscures the fact that the opioid crisis has particularly affected some of the poorest regions of the country, such as Appalachia, and that people living in poverty are especially at risk for addiction and its consequences like overdose or spread of HIV. The Centers for Disease Control and Prevention (CDC) considers people on Medicaid and other people with low-income to be at high risk for prescription drug overdose.

Some of the reasons have to do with access and quality of health care received by people in economically disadvantaged regions. According to the US Department of Health and Human Services, people on Medicaid are more likely to be prescribed opioids, at higher doses, and for longer durations—increasing their risk for addiction and its associated consequences. They are also less likely to have access to evidence-based addiction treatment. But psychological factors also play a role. Last year, economists Anne Case and Angus Deaton attributed much of the increased mortality among middle-aged white Americans to direct and indirect health effects of substance use especially among those with less education, who have faced increasing economic challenges and increased psychological stress as a result.

Environmental and social stresses are an important predictor of many mental disorders, and decades of research using animal models have told us a great deal about how such stresses increase risk for substance use and even make the brain more prone to addiction. Among the best-known animal models of environmental stress and addiction risk are those involving social exclusion and isolation: Solitary animals show greater opioid self-administration than animals housed together, for example—a finding originally made famous by the “Rat Park” experiment of Bruce K. Alexander in the 1970s and replicated by other researchers.

Even more pertinent to the question of how low social status might affect addiction risk is research by Michael Nader, who showed that male monkeys who are dominant in their social group demonstrate less cocaine self-administration than lower-ranked (subordinate) animals or solitary ones. Some evidence point to brain circuitry in the insula (a region important in processing social emotions) that may link feelings of social exclusion to increased drug craving, as well as possibly altered dopamine-receptor availability in the striatum (part of the reward circuit) depending on social status. The relationship may be bidirectional—exclusion not only increases risk for using drugs but increased drug use can increase social isolation further, in a vicious cycle. By the same token, when people have strong family or community relationships, these can act as protective factors against the risk of becoming addicted, and can facilitate recovery among those striving to achieve it.

Another animal model of environmental stress is an environment without opportunities for play, exploration, and exercise. Rodents housed in unenriched environments have been shown to be more sensitive to the rewarding effects of heroin compared to those in more enriched environments. A team of researchers at the University of Texas Medical Branch in Galveston recently explored the molecular mechanisms that mediate the protective effects of enriched environments. They analyzed the transcriptome—or the parts of the genome that are expressed—in the nucleus accumbens (part of the reward circuit) following cocaine exposure in animals raised in either enriched or dull environments. They identified a number of molecules and signaling pathways, including a pathway involving retinoic acid (a product of Vitamin A metabolism), that may underlie the effects of an enriched environment on the brain’s processing of reward. The researchers suggest that the mild stressors and surmountable challenges presented by an enriched environment act to “inoculate” against stress, making individuals in those environments more resilient.

Although highly simplified, animal models of social and environmental stress can tell us a great deal about how stressful human environments may act as risk factors for substance use and other adverse outcomes and, conversely, how socially supportive and rewarding environments may offer protection. Prevention efforts targeting some of the environmental determinants of substance use, especially in young people, have already shown great success by applying the principles of boosting social support and creating the human equivalent of “enriched environments.” For example, a primary prevention model implemented in Iceland drastically reduced teen substance use in that country by increasing parental involvement and youth participation in team sports.  

Blame for the opioid crisis now claiming 91 lives every day is often placed on the supply side: overprescription of opioid pain relievers and the influx of cheap, high-quality heroin and powerful synthetics like fentanyl, which undoubtedly have played a major role. But we cannot hope to abate the evolving crisis without also addressing the lost hope and opportunities that have intensified the demand for drugs among those who have faced loss of jobs and homes due to economic downturns. Reversing the opioid crisis and preventing future drug crises of this scope will require addressing the economic disparities, housing instability, poor education quality, and lack of access to quality health care (including evidence-based treatment) that currently plague many of America’s disadvantaged individuals, families, and communities.

This page was last updated October 2017

Comments

Practical biomarkers for addiction

We desperately need practical biomarkers for addictive disorders (especially opioid abuse which is front and center). By practical, I mean reliable and consistent physiological tests that can be done in medical offices and clinics, not just in laboratories. I fully respect that this will take a lot of time to develop. But such biomarkers would allow us to identify those at various levels of risk BEFORE they are prescribed a drug with addiction potential, and the potential for reducing direct and indirect costs of addictive disorders would be incalculable. I would like to request an article targeted towards the public on the current state of biomarkers for addiction, along with challenges and opportunities. Thank you.

Wait a minute!

The Great Depression with rampant poverty, joblessness and despair, followed by World WarII, was arguably the most stressful time in American history. So how can NIDA explain why opioid addiction was not a crisis in those years like now?

Nonetheless in recent months, I myself am a convert to this current notion that addiction strikes most heavily on the poor and disadvantaged. I am particularly distraught with how addiction occurs on some of our Indian Reservations, and how now, besides alcohol, all the other illicit, recreational drugs are infiltrating. I used to think that some individuals were essentially "doomed" with a genetic vulnerability to addiction, but now concur more factors play a role. Economic prosperity is a lofty goal for all, and if improved conditions can mitigate the opioid crisis, so much the better.

However, remember that correlation is not causation! Perhaps addiction and drug use in the lower classes is the self-defeating lifestyle choice that leads to poverty.

Interestingly, my sister-in-law recently told me she had a surgery for which she was given 100 opioid(type) pills of which she only used one. Friends and acquaintances were begging for the rest!

The ever-growing, recreational drug epidemic we have now might be one of America's greatest challenges ever. In fact, despite whatever economic policy we adopt, it could be that recreational drug abuse and addiction are the primary culprits hindering recovery from the recent Great Recession. Top priority should be to stop the supply of recreational drugs, and stop the demand!

Opioid Epidemic

Changes in the amount of poverty did not cause the opioid epidemic. The epidemic was due to the unchallenged claim in 1986 by Portenoy and Foley that treating chronic pain in medical patients with opioids rarely caused addiction. That claim was used by drug companies to aggressively market OxyContin and other opioids in Appalachia and other low income rural areas. Why didn't NIDA fund or conduct research to demonstrate beyond any doubt that the claim was unfounded?

opioid crisis

There is a fact that everyone seems to be missing. In Chicago, the drug of choice always seems to be heroin whether pure or adulterated. In the poorest areas of this city, there has been an opiate crisis for years! Why is everyone ignoring this? By the way, I am a counselor/therapist at a methadone clinic and have worked here since 2000.

Hold on!

OK, correlation may not be causation but to say because there wasn’t an opioid crisis during the Great Depression means that the science is flawed - is a flawed argument.

First, I did not experience the Great Depression myself so I don’t have any personal experience. I also know that the history we are taught or exposed to doesn’t always tell the whole story. There may not have been an opioid crisis but there were people that committed suicide or became alcoholics (which was a much easier drug to get at that time) - I know from previous study on the roller coaster of addiction rates throughout history that it does spike within certain socioeconomic groups that are in stressful groups with the most readily available drug. Opioids are the current most readily available addictive drug (along with alcohol - I’ve read that 1 in 5 Americans are addicted to alcohol).

I was afraid that some would take the information that lower income, less educated groups are struggling more with addiction because of their “weakness or character’ or attribute addiction to bad choices, being lazy, welfare scamming, etc. by others who have no empathy or understanding of what it’s like to be where they are, the challenges and hopelessness they find themselves in - many by birth and not by choice, by the way.

This article supports my experience with addicts and recovery - it makes perfect sense to me based on what I know personally.

Thank you!

SUD and connections to psychosocial stressors

As a clinician of over 40 years experience, here are my observations about SUD.
The US society is deeply embedded with the idea the biological agents are the natural response to disease and dis-ease. We are only 1 of 2 countries that allow DTC ads. These ads are multiple, and always show how happy "actors" are when ingested. Both legal and illegal drug peddling efforts are quite profitable!!

And when we look deep into our anthropological record, some among us have been quite taken with psychoactive substances and altered states. Psychosocial factors as noted in the article play a major role in drug initiation. Psychosocial interventions like counseling and psychotherapy are also integral to sustained recovery.

We still have a lot of work ahead of us,
Rich

opiods, biomarkers and socio-economics the chicken egg issue

Hello, Ed Francell Jr., the biomarkers are so hard to isolate. They are general markers and have a predictive value. What they predict is less than a direct link. We have tried for a long while to do this wityh alcoholism. We find that it is related, biochemically, to the opiate addictions, and more generally all obsessive "addictive behaviors" and in cases we find the same medications effective. It is not the science we need as much as science informed treatments. There is plenty of pseudo science going around (again) - did we not kill that after the experience of returning V. Nam vets? No! Did Rat Park not open everyones' eyes? No! We are still hung on immutable free will balderdash or the opposite camp of pure brain disorder caused by use. Like so much, we are reduced to extremes.

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    Dr. Nora Volkow: Video Highlights

    NIDA Director, Dr. Nora D. Volkow Videos

    • Charlie Rose, October 2017 - Opioid Addiction
    • National Committee for Quality Assurance (NCQA): Quality Talks, October 2016
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    • The World Science Festival, May 2013
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    • Rockburn Presents, November 2012
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    • Brookhaven National Laboratory WBNL Video, October 2012
      Chemistry celebration: FDG: Contribution to Our Understanding of Addiction
    • CBS 60 Minutes, April 2012
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    • Science Times, June 2011
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