Social Determinants of Health Can’t Be Extricated from Addiction Science

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This article originally appeared in the American Psychological Association’s Society for Psychopharmacology and Substance Use Division 28 Newsletter

A few years ago, I visited a methadone clinic in Baltimore and sat with several of the patients discussing the challenges they faced sticking with their treatment for opioid addiction. Every one of the individuals around the table told me the same thing: The biggest challenge was not having a place to sleep. Without housing, so much of their time was consumed arriving early enough to a shelter so that they could get a room, or other logistical challenges related to their basic life necessities—obtaining meals was another challenge—that they frequently could not make it to the methadone clinic on a given day.

Talking to these patients demonstrated to me that treatment isn’t just about the delivery of a medication or some other intervention that works in ideal laboratory conditions. It is also about the social and economic factors that shape people’s real lives, day to day. Across many institutes of the NIH, research is increasingly focusing on social determinants of health: factors like work and housing instability, food insecurity, racism, class discrimination, immigration status, and stigma and their integral role in shaping risks and treatment outcomes for many health conditions. Understanding and finding ways to intervene in such factors are now also central priorities for my institute, the National Institute on Drug Abuse.

The NIDA and NIAAA -led nationwide longitudinal Adolescent Brain Cognitive Development study is already yielding striking new science on some of the neurodevelopmental mechanisms by which various forms of social adversity influence many aspects of mental health. Mitigating the adverse effects of environmental risk factors like social-economic disadvantage has long been a target of NIDA-funded substance use prevention research, and with projects like the HEALing Communities study, we are now bringing a similar mindset to addiction care and recovery. For instance, data is being gathered on how providing transportation to patients receiving medication for opioid use disorder increases retention in treatment.

Measuring social determinants of health can help researchers better design treatment interventions and services, as well as make addiction care more equitable. Research in other areas of medicine has already revealed the distorting effects of failure to take that step. For instance, a 2019 reanalysis of the data from a huge international clinical trial of hypertension medications found significant disparities in blood-pressure control, all-cause mortality, and various heart-related outcomes depending on whether participants had received their care in low-income versus high-income neighborhoods—differences not accounted for by the medications participants received or by their clinical characteristics, and ignored in the original analysis.

In clinical trials of new medications to treat addiction, it is crucial that we take into account social determinants that influence participants’ access to quality healthcare. Besides enhancing clinical science, measuring such factors could also help personalize our approach to addiction treatment, for instance by helping determine which patients in opioid addiction treatment might benefit from counseling or other services in addition to medications.

No aspect of health exists in a bubble, and this is especially true of substance use and addiction. Researchers keep in mind the diversity of people affected and how their different social contexts and circumstances affect their prospects, especially when those factors can be modified to make treatment more successful and recovery more likely.