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It has been observed that people somaticize social disasters into physical pain. Subjective economic hardship was associated with new onset low back pain following the Great East Japan Earthquake. Intensifying substance use may be a normal societal response to mass traumatic events, especially when experienced by people in lower socioeconomic strata. Increased alcohol use and binge drinking were noted after Hurricanes Katrina and Rita, with the greatest compensatory drinking among those with lower lifetime income trajectories. Women experiencing work stressors after September 11, 2001, were more likely to have increased alcohol use. Longitudinal housing relocation studies suggest that drug use improves when people move to neighborhoods with less economic disadvantage. Adverse childhood experiences have been strongly linked to subsequent substance use; likewise, childhood trauma, is associated with increased opioid use years later. People who use heroin in a deindustrialized steel production area of Pennsylvania cited economic hardship, social isolation, and hopelessness as reasons for drug use, explicitly calling for jobs and community reinvestment to stem overdoses. Yet, some communities’ protective family and social structures generate resilience that mitigates negative impacts from the collision of economic hardship, substance use, and depression. Collectively, these observations challenge us to expand our conceptualizations of the opioid crisis beyond the vector model. A seminal National Academy of Sciences report provides this summary: overprescribing was not the sole cause of the problem. While increased opioid prescribing for chronic pain has been a vector of the opioid epidemic, researchers agree that such structural factors as lack of economic opportunity, poor working conditions, and eroded social capital in depressed communities, accompanied by hopelessness and despair, are root causes of the misuse of opioids and other substances. TO TURN THE TIDE, FOCUS ON SUFFERING The observation that Canada and the United States have the highest per capita opioid analgesic consumption is central to the belief that these medicines are overprescribed, leading to the unrealistic expectation that curtailing dispensing will automatically reduce overdose. In practice, overprescribing is an amalgamation of prescribing behaviors encompassing starting dose, number of units in a prescription, dosing schedules, potency, and other factors. A rational approach would treat these as parallel but distinct issues. Yet, the legislative and clinical reaction has included efforts to bring dosage below arbitrary targets or abandon patients who do not conform to clinically arbitrary expectations. The emphasis on prescribing volume may be a manifestation of subconscious racial bias that frames the famously White opioid crisis as inadvertently induced by physicians; this stands in direct contrast with previous drug panics perceived to afflict minorities, whose drug use was considered a moral failing. This framing, along with the medicalized view of addiction, leaves intact the dignity of people seeking drug treatment—no doubt a positive rhetorical change if applied to all people. Yet, we have spent decades pathologizing members of minority communities for turning to drugs to cope with social stressors and structural inequities. That these phenomena may also afflict White, rural, and suburban communities is emerging as a new realization in public discourse. However, overdose is not isolated to these areas: approximately 41% of drug overdose deaths occur in urban counties, 26% in the suburbs, 18% in small metropolitan areas, and 15% in rural communities. Native Americans are disproportionally affected by overdose deaths as are African Americans in Illinois, Wisconsin, Missouri, Minnesota, West Virginia, and Washington, DC, among other places. This is not merely a story about disadvantage (in income, race, place, etc.). On the basis of epidemiological studies, structural advantages in health care access may have contributed to increased opioid prescribing and availability among White patients. However, reverse associations were observed in controlled clinic-based experiments in which Black patients ended up receiving more opioids, possibly mediated through interactions with patient assertiveness, physician gender, and cognitive load. Regardless, the experience of many seeking health care to manage long-term pain and substance use disorders is tinged with racial undertones. Diez Roux warns: We should guard against the unintended consequence that the focus on the increase in death rates in some Whites (significant as they are) detract attention from the persistent health inequities by race and social class, which are so large that they dwarf the size of what is a very troublesome increase in some Whites. Alas, the US health care system is unprepared to meet the demands elucidated by a structural factors analysis. Even at the patient level, the intersection of social disadvantage, isolation, and pain requires meaningful clinical attention that is difficult to deliver in high-throughput primary care. Some providers struggle with addressing complex, chronic medical conditions requiring regular follow-up, especially with limited recourse to nonpharmacological alternatives and the predominantly urban concentration of specialty services. Patient contracts, urine drug tests, and prescription monitoring can generate mutual distrust in the provider–patient relationship when applied inconsistently, giving rise to uneven care delivery and inducing perceptions of intentional mistreatment.
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