Our Problem Is Bigger Than Opioids

In the depths of the current U.S. drug overdose crisis, the cliché that "addiction does not discriminate" has become the new rallying cry for raising public sympathies for individuals and families struggling with addiction. Technically, the statement is true. There is no magic immunity from opioids or other drugs. The teenage child of a lawyer or banker can just as easily overdose as a homeless person. However, rates of drug addiction and overdose are much higher in some places than in others. The physiological processes of addiction may not discriminate, but the conditions that place people at risk of addiction and overdose are more prevalent in some places than others.

My recent research using CDC data shows that, in addition to access to opioids, there are three main groups of factors that explain why fatal drug overdose rates are higher in some places than others: economy/work, family and community. Counties characterized by higher rates of poverty, joblessness, disability, single parent families and divorce/separation in 2000 have much higher rates of drug mortality now, nearly two decades later, even among places with similar access to opioids.

The effects of these factors are staggering. For example, I estimate that over the past 10 years, there were over 40,000 excess drug deaths among counties ranked in the top 25 percent of economic distress. The implication is that these deaths likely would not have occurred had these counties had similar economic conditions of those in the bottom 25 percent of economic distress. I also find that community-level social infrastructure, such as the presence of churches and other religious venues, is protective against high drug overdose rates. Opportunities for social interaction can help build trust and social cohesion and increase residents' sense of belonging. Yet, as noted by Eric Klinenberg in his recent book, "Palaces for the People," communities have been disinvesting in social resources over the past several decades.

What do these three factors – work, family, and community – have in common? These are the three arenas to which most of us attribute meaning in our lives. Our participation in these institutions is the reason so many of us get out of bed in the morning. But in many places, these institutions have been unraveling for the past three decades, leaving some of us feeling isolated and disconnected. Lack of connection to jobs, family and community is a common sentiment among many of the research participants who are struggling with opioid addiction interviewed in southwestern Pennsylvania in 2018. John, 29 (named changed to protect privacy), told us: "I seen pictures of it [McKeesport, Pennsylvania] back 50 years ago, it was pretty good. I seen pictures of businesses and stuff and now walking there's like…everything else is boarded up and stuff." Similarly, Ava, 26, of Clarendon, Pennsylvania, told us: "When I was little, it used to be pretty, everything was upbeat, there were people, and now there's nothing. It went downhill really bad."

Some experts have argued that the U.S. overdose crisis has been driven almost entirely by changes to drug environments -- namely the surge in prescription opioids. For good reason, substantial criticism has been levied against Purdue Pharma and the other pharmaceutical companies who manufactured and aggressively marketed OxyContin and other opioids. To be sure, the emergence and widespread availability of powerful and incredibly addictive prescription opioids was the spark that started the current overdose epidemic, which has since transitioned into heroin and fentanyl epidemics. But you cannot start a fire without kindling. Opioids are the substances directly killing people, but opioids are a symptom of much larger social and economic problems facing the hardest hit communities. Opioid overprescribing was not geographically random. It is no coincidence that pharmaceutical companies targeted, and widespread opioid prescribing first emerged in, the most economically vulnerable places in the U.S., particularly those with high rates of poverty, joblessness, pain and disability.

OxyContin and other strong opioids were heavily marketed in mining-dependent Appalachian communities long before they spread across the rest of the U.S. Of the 100 counties with the highest fatal drug overdose rates in the U.S., 80 of them are within the heart of Appalachia (West Virginia, Kentucky, Tennessee) or the former U.S. industrial belt (Ohio, Pennsylvania, Indiana). What these places have in common is sustained devastation to their blue-collar industries, intergenerational poverty and little opportunity for upward mobility.

In his national best-seller, "Dreamland: The True Tale of America's Opiate Epidemic," Sam Quinones writes about Portsmouth, Ohio - a blue-collar city with a once thriving manufacturing base anchored by shoe, steel, brickyard, atomic energy and soda factories. By the 1990s, these factories were long gone, replaced by big-box stores, check-cashing and rent-to-own services, pawn shops, scrap yards, and the nation's first large pain clinic where physicians doled out prescriptions for OxyContin and other narcotics like candy. Portsmouth was soon the pill-mill capital of America, with more prescription pain relievers per capita than any other place in the country. In today's Portsmouth, median income is lower than in 1980, and poverty, disability and unemployment rates are all high. A full 43 percent of prime working-age men (age 35-54) are unemployed or out of the labor force altogether.

Likewise, for several decades, McDowell County, West Virginia, was the world's largest coal producer, but the county has seen a devastating and sustained erosion of its population from almost 100,000 in 1950 when coal was king, to about 19,000 today. As coal declined, lower paying service jobs became the main source of employment, but now those have disappeared, too. Even the Walmart there closed in 2016. McDowell County, and places like it, consistently have among the highest drug overdose rates in the U.S.

The upside of the cliché - "addiction does not discriminate" - is that it forces us to acknowledge that addiction is not due to personal pathologies or the cultural problems of inner cities, as was the harmful sentiment during the crack-cocaine epidemic of the 1980s. The drawback is that resources and intervention efforts may not be appropriately targeted to the places with the greatest need. Supply-side factors matter, but the opioid problem reflects economic and social conditions that prevailed decades ago with the dynamics playing out now. Solutions to combat the opioid crisis will only be effective if they address the social and economic determinants at the foundation of the crisis.