The Social Determinants of Drug Abuse

Transcription

1 The Social Determinants of Drug Abuse Investigation into the Etiology of the Opioid Epidemic Bioethics Symposium South Carolina Medical Association April 28, 2018

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9 Objectives Briefly review the Social Determinants of Health (SDH) and the influence each may or may not have on drug, both prescription and nonprescription, abuse. Delineate and dispel urban myths concerning the Opioid Epidemic. Propose achievable goals in the War on Drugs.

10 DISCLAIMERS I have submitted the requisite form for Disclosure of Potential Conflicts of Interest; I have none to disclose. This presentation is solely the position of the presenter and the numerous sources referenced, and does not represent an official position of the SCDHEC, USCDC&P, or the SCMA. I do freely admit to non-intentional (sic) plagiarism

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12 Theories on the Etiology of the Opioid Over prescribing Crisis Uneducated prescribers Formulary changes dictated by Insurance Companies Legislative initiatives Unethical prescribers pill mills, etc Societal expectations

13 Determinants of Substance Abuse Biological, social, environmental, psychological, and genetic factors are all associated with substance abuse. Other factors include gender, race and ethnicity, age, income level, educational attainment, and sexual orientation.

14 Determinants of Substance Abuse Substance abuse is also strongly influenced by interpersonal, household, and community dynamics. Family, social networks, and peer pressure are key influencers of substance abuse among adolescents.

15 Social Determinants of Health The conditions in which people are born, grow, live, work and age factors that shape people s health beyond their lifestyle choices and medical treatments. The social determinants of health are mostly responsible for health inequities---the unfair and avoidable differences in health status seen within and between countries. World Health Organization

16 Social Determinants of Health Life s circumstances are shaped by the distribution of money, power and resources at global, national and local levels. Early-childhood development/ education Food insecurity, housing, social exclusion/inclusion, and the social safety net Unemployment/employment, income, job security, working conditions Health services Race, gender and ethnicity

17 Social Determinants of Health SDH encompasses socioeconomic status, race, ethnicity, education, family structure, diet, food security, physical activity, local economic development, employment, working conditions, financial resources, housing, location, the built environment, recreational spaces, neighborhood crime, median neighborhood income, intimate partner violence, transportation, stress, social connections, social isolation, homelessness, and physical disabilities.

18 ZIP CODE What are the factors that make your zip code a stronger determinant of health than your genetic code? Studies indicate that addiction (substance abuse) may be one inevitable by-product of inequitably constructed social spaces, where poverty is a powerful structural force that erodes relational stability and undermines individual and community health. Institute of Medicine (NAMS)

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21 The Food Desert

22 Social Determinants of Health Environmental factors, such as lead paint, polluted air and water, dangerous neighborhoods, and the lack of outlets for physical activity.

23 Social Determinants of Health One must also consider: opportunities for education, socioeconomic status, poverty, median income the physical and social environment employment, or lack thereof discrimination.

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25 Addressing the Opioid Crisis Means Confronting Socioeconomic Disparities The determinants (causes?)of this problem are many: poverty, widening income disparity, underinvestment in social infrastructure, lack of health insurance coverage and lack of access to health care.

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27 FACT With respect to social factors, people with lower socioeconomic status die earlier and have more disability than those with higher socioeconomic status, and this pattern holds true in a stepwise fashion from the lowest to the highest classes. Perhaps drug use/addiction in the lower classes is the self-defeating lifestyle choice that leads to poverty.

28 Caveat In this context, class is a composite construct of income, total wealth, education, employment, and residential neighborhood. More fundamental, however, is the recognition that social policies involving basic aspects of life and wellbeing (e.g., education, taxation, transportation, and housing) all have important health consequences. Remember that correlation is not causation!

29 Impact of SDH Factors Healthcare accounts for only 10 percent to 25 percent of the variance in individual health over time.

30 Common Myths Addiction rare in patients treated with narcotics. Porter J, Jick H. N Engl J Med Jan 10;302(2):123. This crisis started not on a street corner somewhere. This crisis started in the doctor s offices and hospitals of America. (Christie, 2017) Drug addiction is a chronic illness, like hypertension or diabetes. All addicts are poor, unemployed, homeless and uneducated. Most are from ethnic minorities, i.e., African-American or Hispanics. Most heroin addiction starts with a legitimate pain prescription, and most prescription opioid misuse leads to heroin addiction. Opioid addiction is just a psychological disorder and people who are dependent simply need better willpower.

31 Michael Jackson, Elvis, Prince, Janis Joplin, Heath Ledger, Chris Farley, Kurt Cobain, Jimi Hendrix, Billie Holiday, River Phoenix, Phillip Seymour Hoffman, Whitney Huston, Anna Nicole Smith, Jim Morrison, Jim Belushi, Cory Monteith, Dana Plato, Syd Vicious, Hank Williams, Tom Petty, and on, and on, and on. Consider

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33 Winnable Goals in the War on Opioid Abuse Establish realistic pain management expectations and guidelines Pharmaceutical companies Over prescribers More, and better trained, pain management specialists Legalize marijuana for chronic pain management??

34 Winnable Goals in the War on Opioid Abuse Good Samaritan laws and Naloxone access Sentencing reform Reality-based drug education Syringe exchanges, safe sites Healthcare providers Not all well intentioned approaches to addressing the opioid epidemic are good ideas. Sharfstein, J. JAMA Forum: A New Year s Wish on Opioids; January 3, 2018

35 Simple Solution Address upstream social determinants-including economic resources, education, and racial discrimination-all factors that fundamentally shape the downstream determinants, such as behaviors, targeted by most interventions. Recognize that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities all affect people s vulnerability to substance abuse.

36 Where to begin?

37 References Available by request to:

38 Questions or Comments?