level of fatal overdose likely to decrease”
(Frisher et al., 2012, p. 31)
Before talking about specific strategies of overdose prevention, we need to ask ourselves if OD is simply an individual health issue that could be “cured” improving health responses and maximizing its access. If we believe so, we fail to answer why poverty, as Cohen, Farley and Mason (2003) stated, is unhealthy, i.e., why social economic status is strongly associated with mortality rates. Why, as Holmes (2002) stated “if poverty were a disease it would be the most insidious, devastating and life threatening disease that Americans suffer” (Holmes, 2002, p.5)? Poverty is associated with higher death rates, lack of access to health care, lack of access to education, higher rates of imprisonment and death penalties. Why, as stated by Commission on Social Determinants of Health (2008), a girl born today could have a life expectancy of 80 years if she is born in some countries and half of this rate if she is born in others. Also, we ask why within countries, the levels of social disadvantage are closely associated with such dramatic differences in health (ibidem). We need to ask ourselves why socioeconomic inequalities have such impact in mortality rates, namely for causes of death that are preventable (Phelan, Link, Diez-‐Roux, Kawachi & Levin, 2004).
We have to ask ourselves why social stigma is “a fundamental driver of population health” (Hatzenbuehler, Phelan, Bruce & Link, 2013, p. 813) and why there are more stigmatizing societies than others. We need to ask ourselves for what reason people at the margins of society are most at risk of developing a drug problem (Shaw, Egan & Gillespie, 2007). We urgently need (and more than ever) to address social and economic determinants on drug abuse and its consequences, such as overdoses and infectious diseases associated with drug consumption, if we want to present effective responses at European level.
In 2012, the Civil Society Forum on Drugs highlighted (as one of the 16 recommendations to the EU Member States and to the European Commission regarding the new EU Drugs Strategy
and Action Plan) the need to take into account the social/economic dimensions on drug policies:
Poverty, Deprivation, social inequality, discrimination and stigma must be given their full and proper place in all considerations of drug demand reduction policies, at local, Member State and European levels (Civil Society Forum on Drugs, 2012, p.6).
This same recommendation has been previously stressed by other reports such as the document published by the Scottish Drugs Forum (SDF) on behalf of the Scottish Association of Alcohol and Drug Action Teams:
Relative poverty, deprivation and widening inequalities, such as income, are important factors that need to be given a more central role within the drug policy debate as they weaken the social fabric, damage health and increase crime rates (Shaw et al., 2007, p.3)
Research developed in this field has shown that substance use rates, patterns of consumption, number of people on treatment, and the marginalization of consumption and consumers are associated with economic and social indicators such as unemployment and poverty rates (e.g., Arkes, 2007, 2011; Ritter & Chalmers 2011; Lakhdar & Bastianic 2011; Storti, Grauwe, Sabadash & Montanari, 2011). One of the most developed indicators in this field refers to the association between measures of social inequalities and abusive substance use. In fact, it seems that countries with higher social inequalities rates and lower social cohesion rates face additional challenges in what concerns the number of problematic drug users per head of population (CSFD, 2012).
However, in spite of the consistent data on social and economic determinants on problematic drug use, in what concerns drug-‐related and drug-‐induced mortality, the number of studies is still very limited. Crude mortality rates for PWID seem to be higher in low and middle income countries when compared with high income countries (Mathers et al., 2013). Wilkinson and Picket (2007) found a large correlation (r = 0.60, p < 0.001) between the number of overdoses and state income inequality in USA (see figure 9). In a study carried out in 59 residential community districts in New York City, within a two year period (1990-‐1992), Marzuk and colleagues (1997) found out that poverty status seem to predict 69% of the variance in drug overdose mortality rates. Gale and colleagues (2003) have also found that overdoses in New York City were more likely to occur in more inequitable neighbourhoods, independently of the
demographic characteristics such as age, race and sex. This data led the authors to stress the need of considering the neighbourhoods’ level of inequality when conducting public health interventions on overdose. In another research developed more recently, Cerdá and colleagues (2013) found a different pattern of drug fatalities when comparing heroin fatalities, analgesic fatalities, and non-‐overdose fatalities in New York City neighbourhoods. “Whereas analgesic fatalities typically occur in lower-‐income, more fragmented neighbourhoods than non-‐overdose fatalities, they tend to occur in higher-‐income, less unequal, and less fragmented neighbourhoods than heroin fatalities” (Cerdá et al., 2013, p.2). The authors stress the need to identify, in future studies, the specific mechanisms of neighbourhoods underlying heroin and analgesic overdoses. Despite the conclusions of the previous studies, which emphasise the need of considering socio-‐economic variables on the prevention of problematic drug use and overdoses, there is still a lack of research concerning the mediating and moderating dimensions of this association. One potential mediator is the marginalization and stigmatization of these populations (Room, 2005). Moreover, this dynamics seems to feed back up, since stigma seems to be a fundamental driver of population health inequalities (Hatzenbuehler et al., 2013), namely in such stigmatized groups such as drug users (Ahern, Stuber & Galea, 2007). “The association of stigma and discrimination with poor health among drug users suggests the need for debate on the relative risks and benefits of stigma and discrimination in this context” (Ahern et al., 2007, p. 188).
Figure 9: The use of illegal drugs is more common in more unequal countries
Notes: Image courtesy by the authors.
References: Wilkinson & Pickett, 2009, p. 71
The research on this topic should be further supported and include comparative studies on the impact of broader variables such as inequality measures, the unemployment/risk of poverty ratio on overdoses rates. Drug action plans and interventions, including the ones targeting overdoses, should also stress the need to define consistent environmental prevention strategies. According to EMCDDA:
Environmental strategies are prevention strategies aimed at altering the immediate cultural, social, physical and economic environments in which people make their choices about drug use. This perspective takes into account the fact that individuals do not become involved with substances solely on the basis of personal characteristics
(EMCDDA, 2012 February 24).
In spite of the scientific community perception that problematic drug use causality is complex and involves the combination of biological, psychological and social dimensions, the majority of interventions are still pretty much confined to universal, selective and indicated preventions strategies. Thus, they neglect broader socio-‐economic measures to prevent social exclusion and the cluster of pernicious dimensions associated with it, such as problematic drug use and its direct and indirect consequences. This doesn’t mean that all marginalized people will develop a drug problem, but that they are at most risk of developing it (Shaw et al., 2007). If we neglect that, we will fail to delineate upstream preventative measures regarding drug-‐ related mortality.