The Interconnectedness of Poverty, Homelessness, and Addiction

It’s not just the drugs.

A common saying is that "addiction doesn't discriminate," which means that it can affect anyone from any sphere of life, ranging from coal miners, construction workers, and truck drivers to executives, doctors, and lawyers. As a primary care doctor, I have had personal experience with what an equal-opportunity destroyer of well-being and happiness addiction can be. Currently, I am seventeen years into recovery from a vicious addiction to prescription painkillers. My addiction didn't care about my education, medical degree, race, gender, religion (or lack thereof…), social status, or health. Neither did the state police and the DEA, who raided my office, charged me with three felonies, had me booked, fingerprinted, and attempted to crucify me in court. I overdosed a few times and am lucky to be alive.

Social determinants of health and addiction

In another, critical sense, addiction does discriminate among people, in a way that is unjust and deadly, and in a way that shines a spotlight the fraying socioeconomic web that is decreasingly holding our society together. According to the World Health Organization, Social determinants of health (SDoH) are defined as "the conditions in which people are born, grow, live, work, and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels." It has long been observed by clinicians that SDoH can tip the scales against people, in their already daunting quest to recover from any type of addiction.

Even with every possible advantage in my favor – White, educated, respectable job, healthy and cohesive family, etc. - getting over my addiction was, by far, the most difficult thing I have ever accomplished. Compared to my attempts to get and stay in recovery, with the crushing withdrawal symptoms and all-consuming cravings, every aspect of medical school, which is known for its physical deprivations and soul-crushing stress, was a breeze. Even when the state police and the DEA raided my office – not fun! – I knew, on some level, that everything would be OK.

I have infinite respect for, and humility towards, those who have been able to transcend their addictions without my advantages.

The profound effect that SDoH have on people struggling with addictions is borne out by the evidence. In a 2019 study from Drug and Alcohol Dependence it was found that "across 17 states in 2002–2014, opioid overdoses were concentrated in more economically disadvantaged zip codes, indicated by higher rates of poverty and unemployment as well as lower education and median household income." Other studies have found poverty to be a risk factor for opioid overdoses, unemployment to be a risk factor for fatal heroin overdoses, and a low education level to be a risk factor for prescription overdose, and for overdose mortality. Homelessness has been shown to be associated with overdoses as well, particularly among veterans. Incarceration is associated with abysmal outcomes across the board, particularly the period immediately after release, when deaths from overdoses skyrocket, as there is little structure or help for people who are struggling. Systemic racism worsens every single one of these facets of our addiction crisis.

A photo from Boston’s ‘Mass and Cass’ area where the interplay of addiction, poverty, and homelessness is hard to miss. “DO NOT ENTER is correct. Do not enter into the nightmare of addiction in the first place!