Why Opioid Misuse Policies Must Comprehensively Address Social Determinants of Health to be Effective

In 2017, there were more than 70,000 cases of opioid overdose. ¹ The opioid misuse that pervades the United States is largely a result of systemic social problems. Comprehensive, well-rounded policy is critical in mitigating the effects of the epidemic.

Public attention has largely focused on lawsuits against pharmaceutical companies and prosecution of physicians across the nation. Although these may be necessary provisions for correcting prior injustices, they can often blind us to the complex array of underlying determinants of opioid misuse.

The term “deaths of despair” ² refers to the surge of suicides attributed to alcohol and drug-related deaths. These “deaths of despair” are not equally distributed across the nation—and the geographical differences are indicative of many forms of stagnation. In many regions across America, there is a substantial decrease of labor force involvement, lack of wage growth, and an associated decrease of opportunity for social interaction.³ The combination of these conditions can often lead to feelings of hopelessness. Moreover, increasing social and economic disintegration is inhibiting opportunities for “connection”—critical feelings of belonging and purpose that have been inherently present in our communities and families in previous decades. Our communities are splintering, and rates of divorce and other indicators of weak family ties are rising.²  Opioids offer an easy and immediate, yet transient solution to these seemingly unfixable problems.²

Policy remedies can result in positive outcomes; however, there are many instances in the fight to address the opioid epidemic in which they have been proven inadequate. For example, the Centers for Disease Control and Prevention (CDC) recently pushed for the discontinuation of prescription opioid use in an attempt to reduce misuse.⁴ This policy reaction creates opportunities for unsafe clinical prescription opioid discontinuation—in turn, leading to poor health consequences that often stem from withdrawal.⁴ This example, among many others, highlights the critical need for policies to address the important nuances of the opioid epidemic.

To support the thousands of individuals struggling with opioid addiction, we must acknowledge and address the disparities that exist in our health care system and society. There are systemic gaps in the way mental health services are prioritized and financed in the U.S. that are visible in the shortage of psychotherapeutic services. Many policymakers have focused on expanding access to opioid-based treatments for opioid use disorder (i.e., medication-assisted treatment), such as buprenorphine and methadone. Additionally, policies about safe injection facilities are beginning to gain more traction. Safe injection facilities are intended to provide sterile injection equipment, a safe environment, free from criminal prosecution, and clinical lifesaving support.⁵

These policies are important preliminary steps; however, they are analogous to putting a Band-Aid on a bullet wound. We must create comprehensive policies to mitigate the inherent sense of isolation through policy that addresses the social determinants of health. For example, in Ohio, the Department of Mental Health and Addiction Services has implemented a scalable framework across twelve rural and remote counties compromised by isolation—the Prevention Institute’s Adverse Community Experiences and Resilience (ACE|R) Framework. The framework aims to guide communities to:

“Advance actions to build community trauma-informed teams; support the development of local theories of change that consider community trauma; reduce stigma that arises when issues are seen solely as problems of individual behavior versus through a broader lens of contributing community factors; and to develop a strategic roadmap that considers underlying factors and root causes driving opioid use disorder." ⁶

The 12 counties have expressed positive feedback about the framework. It has been characterized as “an effective way to explore community determinants of health that also encourages involvement of partners from a diversity of sectors that impact those factors (i.e., pharmacists, physicians, insurers, emergency responders, employers, faith-based organizations, and youth development professionals)." ⁶

As a society, it is imperative that we prioritize this complex social crisis and shape our policies to consider the social determinants of health and reflect the complexity of addiction. Creating more opportunities for social interaction and civic engagement for individuals will lead to increased hope, optimism, and self-efficacy—real, sustainable solutions that offer more than a “quick fix." ³

¹ Centers for Disease Control and Prevention, "Opioid Overdose" https://www.cdc.gov/drugoverdose/index.html
² Karen Dayton, "Why deaths of despair are rising in the U.S.," 2019  https://www.hsph.harvard.edu/news/features/why-deaths-of-despair-are-rising-in-the-u-s/
³ Shannon Monnat, "Drug Overdose Rates Are Highest in Places With the Most Economic and Family Distress," 2018 https://carsey.unh.edu/publication/drug-overdose-rates-highest-place-with-economicfamily-distress
⁴ Centers for Disease Control and Prevention, "CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain," 2019 https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html
⁵ USC Department of Nursing, "Supervised Injection Sites Are Coming to the United States. Here's What You Should Know," 2019
⁶ Prevention Institution "Developing a community-trauma informed approach to the opioid epidemic in Ohio" https://www.preventioninstitute.org/sites/default/files/uploads/PI_ohio_033018.pdf