Opioid Crisis: No Easy Fix to Its Social and Economic Determinants

Abstract

The accepted wisdom about the US overdose crisis singles out prescribing as the causative vector. Although drug supply is a key factor, we posit that the crisis is fundamentally fueled by economic and social upheaval, its etiology closely linked to the role of opioids as a refuge from physical and psychological trauma, concentrated disadvantage, isolation, and hopelessness. Overreliance on opioid medications is emblematic of a health care system that incentivizes quick, simplistic answers to complex physical and mental health needs. In an analogous way, simplistic measures to cut access to opioids offer illusory solutions to this multidimensional societal challenge. We trace the crisis' trajectory through the intertwined use of opioid analgesics, heroin, and fentanyl analogs, and we urge engaging the structural determinants lens to address this formidable public health emergency. A broad focus on suffering should guide both patient- and community-level interventions.

Public health responses to the opioid crisis in North America

“…While much has been done in effort to reduce deaths due to opioid use, little progress has been made, which necessitates a more critical analysis of existing efforts, the continued implementation of novel approaches and a move away from overmedicalising the epidemic and towards considering ways of addressing the upstream social-structural drivers of opioid overdose, including those rooted in social-economic changes, racial disparity and criminalisation. However, as has been pointed out eloquently by Dasgupta et al ,13 there is no ‘easy fix’ to such problems. Still, until a broader approach is taken it is unclear whether the real change in opioid overdose dynamics can be reasonably expected.…”

“…A growing body of literature points to the potent role of social and structural drivers in shaping not only opioid use and overdose, but also an array of other health challenges, including rising rates of mental health problems, suicide and alcoholism 13. Common social-structural drivers of these conditions include socioeconomic disadvantage, such as increasing income disparity, and related social despair and hopelessness,13 as was elucidated in a recent analysis demonstrating that US states with the lowest social capital had the highest rate of overdose death 14. Accordingly, it is time to think beyond conventional medical approaches and develop strategies to ensure income security, access to employment and stable housing as a means of reducing overdose death.…”

“…Accordingly, it is time to think beyond conventional medical approaches and develop strategies to ensure income security, access to employment and stable housing as a means of reducing overdose death. Further, racial disparity and marginalisation also continue to drive death due to overdose 13. In both the USA and Canada, individuals of indigenous ancestry have been disproportionally affected by the overdose crisis, pointing to the need for reconciliation and the development of culturally appropriate policies and programming.…”

The National Opioid Epidemic and the Risk of Outpatient Opioids in Children

“…The present problem is therefore much more one of deaths from illicit drugs than from prescription opioids and more about deaths from illicit use of prescriptions than from medical use of prescription opioids. In other words, we have an epidemic of substance use disorder (SUD) that is embedded in a complicated matrix of despair and hopelessness across the United States and correlates closely with socioeconomic factors such as unemployment, poor education, availability of illicit street and diverted prescription opioids, 15,16 genetic predisposition to SUD, 17,18 and psychiatric morbidity. 19 Thus, there is scant evidence to support the existence of an epidemic of deaths due to the appropriate use of prescribed opioids.…”

Government Actions to Curb the Opioid Epidemic

“…This narrow emphasis crowds out the discussion of more urgent opportunities to mitigate opioid-related harms, including improving care coordination and system integration to address users’ complex physical and mental health needs; expanding evidence-based harm reduction options to include prescription heroin and safe consumption spaces; and focusing on addressing the structural determinants of the opioid crisis. 5 …”