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Sociological Impacts of the Opioid Crisis on the Family

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The opioid crisis: a contextual, social-ecological framework

  • Michael Botticelli3,
  • Rachael C. Hwang2,
  • Howard K. Kohiv,5 &
  • R. Kathryn McHugh1,6

Health Inquiry Policy and Systems volume eighteen, Article number:87 (2020) Cite this commodity

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A Commentary to this article was published on 08 August 2020

Abstract

The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. Notwithstanding, broader social and contextual domains are likewise essential contributors to the opioid crisis such equally interpersonal relationships and the conditions of the customs and social club that people alive in. Despite efforts to tackle the effect, the rates of opioid misuse and not-fatal and fatal overdose remain loftier. Many call for a broad public health arroyo, but articulation of what such a strategy could entail has non been fully realised. In club to improve the sensation surrounding opioid misuse, nosotros developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis equally a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

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Background

The alarming rise in opioid misuse over the past two and a half decades has resulted in a public health crisis, characterised about prominently by a dramatic increase in drug overdose deaths. In 2017, approximately 12 million Americans misused opioids [ane] and more 47,000 people died of opioid overdose [2]. This overdose fatality charge per unit reflects an increase of 345% between 2001 and 2016 [3], with particularly steep annual increases in overdose fatalities since 2015. The growing opioid misuse result was recognised equally a national public health emergency by the United States Section of Health and Man Services in 2017.

Over the terminal several years, opioid misuse gained the attention of scholars, researchers, wellness professionals and politicians [4]. Many accept called for a broad public health approach, but the total breadth of such a strategy has non yet been articulated or realised. While diverse interventions have been implemented over time, they accept by and large been insufficient to slow the growth of non-fatal and fatal overdoses at a national level [5]. Interventions that only target a single aspect of the issue, such as restricting opioid supply, volition not be sufficient to ameliorate the opioid epidemic. This is further complicated by the speedily evolving nature of the epidemic. For example, the widespread availability of fentanyl and fentanyl analogues beginning around 2013 has resulted in a steep escalation of overdose death rates, even as other public health indicators (due east.g. prescription opioid misuse) have begun to ameliorate.

Furthermore, although the years of steeply escalating fatalities have brought newfound attention to the harms of opioid misuse, this problem is not new. Opioid use disorder (OUD) is a disabling disorder with high levels of morbidity and bloodshed that has devastated families and communities for decades. Although the introduction of agonist treatments in the 1970s brought critical relief to many people suffering from this illness, few people received any treatment even prior to the current crisis [6], while increasing criminalisation of drug employ diverted a high proportion of this population to the criminal justice arrangement. Thus, the inadequate public wellness and societal response to the harms of opioids is longstanding and new and expanded responses are sorely needed. The complexity of the crisis is represented by the multiple spheres of influence derived from individual factors, interpersonal relationships, and community and societal influences, indicating the necessity of a broader and a more integrated approach that includes prevention, treatment and overdose rescue interventions in addition to supply reduction strategies.

In this paper, we present a social-ecological framework as an of import step to conceptualise the complexity of the opioid epidemic. This framework can help inform the design of impactful interventions to curb the opioid crisis. We present our framework and provide a brief overview of the literature informing its components.

Social-ecological framework

Our social-ecological framework, illustrated in Fig. 1, depicts the major run a risk factors for opioid misuse on 4 primary levels: the individual, interpersonal, communal and societal (see Additional file ane for our utilize of the term 'framework'). Each of these levels must be acknowledged to develop multifaceted and effective interventions to mitigate the opioid crisis. Post-obit social ecological paradigms [7], prior research has presented frameworks for substance use [8] in general and alcohol apply [ix] in particular. While there are similarities among these frameworks and ours, in that location are essential factors related to opioid misuse, such as the existence of both legal (i.due east. via legitimate prescription) and illegal supply sources and the availability of highly effective medications, that we discuss in this article. In the following sections, we provide a brief overview of how these levels of factors contribute to the opioid epidemic.

Fig. 1
figure 1

Social-ecological framework of the opioid crisis. Socio-demographic factors consist of age, race, gender, ethnicity, education, income and unemployment factors

Full size image

Private level

Individual-level factors in opioid misuse and OUD span sociodemographic, health and mental wellness, biological, and psychosocial domains. Private factors can influence every aspect of the spectrum of opioid use and misuse, including the likelihood of exposure to opioids, initiation of opioid misuse, the development and maintenance of OUD, entry to and appointment in treatment, and relapse following an attempt to quit. These factors are complex, often collaborate and, in some instances, can be both a cause and consequence of opioid misuse (e.g. financial strain).

Many sociodemographic factors interact with opioid misuse, with implications for identifying at-gamble populations. Opioid misuse peaks in early adulthood (approximately eighteen–25 years) [x]. Early initiation of opioid misuse is a meaning take chances factor for the development of OUD [xi] and, thus, adolescence and young adulthood are key run a risk periods for opioid misuse. Gender tin as well play a role in risk for opioid misuse. For example, women are more likely than men to receive an opioid prescription [12, 13] and sex differences in the pharmacological effects of opioids have been demonstrated [14]. Critically, opioids are known teratogens and untreated OUD presents risks to both neonatal and maternal outcomes [fifteen].

Race as well plays a circuitous function in the opioid epidemic. People identified equally non-Hispanic white are more probable to receive an opioid prescription, increasing the adventure of exposure via this route [16]. Disparities in healthcare for hurting often get out pain untreated or undertreated in racial and ethnic minorities [17]. Although the opioid epidemic initially predominantly affected non-Hispanic whites [18], opioid overdose is chop-chop increasing amid racial minorities [19]. Race also impacts access to treatment; the vast majority of studies suggest, unsurprisingly, that racial and ethnic minority groups have less access to treatment. For case, studies show that admission to effective medication for OUD is lower in communities with higher African American and Hispanic populations [xx, 21]. Ane study found that, among people in treatment for OUD, the vast majority did not receive agonist therapies and that opioid agonist prescriptions were modestly college in black and Hispanic clients who used heroin relative to white clients [22]. Yet, many other studies suggest that racial and indigenous minorities face up disparities in access to care such as delayed admissions to handling and lower likelihood of receiving treatment [18, 23]. Another essential component of the role of race in the opioid epidemic is the disproportionate arrest and incarceration of people of color — we will discuss this further in the 'Societal level' section. Additionally, a wide array of health and mental health factors may increase the likelihood of hazard for misuse, some of which overlap with those that increment the likelihood of a prescription (e.g. pain). Pain is a cadre element of the opioid crisis and the majority of people seeking treatment for prescription OUD written report first using opioids for pain with a legitimate prescription [24]. Similarly, mental health factors are a pregnant contributor to opioid misuse. The majority of people with OUD as well suffer from a mood or anxiety disorder [25] and psychiatric symptoms are associated with incident take a chance for prescription opioid misuse [26]. Additionally, a history of other substance misuse and other substance utilise disorders is a significant take chances factor for opioid misuse; it is the most robust predictor of opioid misuse in people with chronic pain [27]. Similarly, polysubstance employ increases the risk of opioid misuse [28] and recent inquiry shows that it is highly prevalent among those with OUD [29].

A number of biological factors and genetic susceptibility tin can also predispose individuals to develop OUD. In addition to biological vulnerability to substance use disorders in general [30, 31], factors that influence the effects of opioids include genetic factors that modify the opioid receptors in the brain [32, 33]. Once physiological tolerance is developed to an opioid, decreases in dose or removal of the medication will result in withdrawal symptoms [34]. Although these symptoms are not fatal, they are extremely aversive and a significant reason for continued opioid utilise and relapse in people with OUD [35]. Indeed, over the course of OUD, the primary reason for use tends to shift to avoiding/relieving withdrawal more than managing pain or feeling good [24].

In this section, nosotros take highlighted some key individual-level factors; however, it should be noted that the they are not meant to be comprehensive. A broad range of other psychological and temperamental factors tin can as well play a office in the opioid epidemic; these include factors such equally impulsivity [36], self-stigma [37] and self-decision [38]. Readiness for change is likewise another factor that is associated with entry into treatment [39] and the change process during the handling [40], although limited information suggest this may not be related to OUD handling outcome [41]. Overall, there is an essential need for more research on the role of these and other similar psychosocial factors.

Interpersonal level

Family, friends and co-workers significantly shape the beliefs, attitudes and behaviours of individuals to influence the likelihood of individuals' initiation and misuse of substances [42,43,44]. A family history of substance utilize disorder can influence opioid misuse through both genetic and ecology factors. People who have a family member with OUD are 10 times more vulnerable to misuse and overdose on the drug themselves and youth witnesses of family member overdose are more prone to overdose themselves [45, 46]. Individuals with a family history of opioid use are at a higher risk of suffering from symptoms of opioid dependence and becoming severely dependent [47]. This may be particularly important for women, for whom the risk of opioid misuse is higher when a spouse or partner misuses opioids [48]. Opioid misuse is besides influenced by the accessibility to opioids from family, friends and/or co-workers. Approximately 70% of people who report non-medical opioid use reportedly obtained opioids from family unit members or close friends [49, fifty]. Co-workers can also exist a source of opioids since most 69% of people who misuse opioids are employed and 10% to 12% report drug use during working hours [51, 52].

Interpersonal relationships influence the actions of individuals to apply opioids and seek treatment. Parental disapproval of drugs discourages substance utilize and families are often the offset to detect drug misuse because of their sensation of substance history [44, 53]. Studies show that family support of recovery tin can increase the likelihood of receiving handling [49, 54]. The emotional back up from social supports tin can increase medication adherence and motivate patients during their treatment sessions [53, 55].

Communal level

The third level of our framework considers the communal settings and their contributions to opioid-related risks [56]. The community and the immediate context in which individuals alive affect their daily behaviours in significant ways. Variables such as geographic conditions, handling accessibility, medication disposal services, workplace environment, prescribers' perception of risk, over-prescription of opioids or nether-treatment of pain, types of prescription opioid formulations bachelor, community norms, and access to legal and illegal opioids are major hazard factors that can perpetuate opioid misuse.

Between 2006 and 2017, approximately 224 1000000 opioid prescriptions were filled annually in the Usa, which is virtually plenty to distribute across the unabridged United states population [57]. Over-prescription of opioids has been influenced by several interacting factors. Ofttimes, physicians' insufficient hurting management preparation and knowledge on opioid misuse chance contribute to their inability to safely prescribe opioids, implement and interpret risk assessments, notice addiction, and facilitate discussions with patients [58,59,60]. Furthermore, prescribers who overestimate the benefits and underestimate the danger of opioids are probable to contribute to over-prescription by providing months' worth of medication when only a few days may be needed for pain direction [61, 62]. The establishment of guidelines (e.g. the Centers for Disease Control and Prevention's Guideline for Prescribing Opioids for Chronic Pain) and other interventions to better prescribing practices has resulted in decreases in opioid prescribing [63], with reductions occurring since 2010 [57].

Over-prescription was likewise influenced by pharmaceutical marketing campaigns that falsely marketed opioids as non-addictive and "create[d] value" for doctors by offering monetary compensations [64]. Doctors who refused to prescribe opioids to patients were labelled equally 'opiophobic' [65]. These incentives include sponsored meals, speaking fees, travel expenses and education [66]. Although just 7% of opioid-prescribing physicians received gifts from drug companies, they were more probable to prescribe opioids to their patients than doctors who did not benefit from the incentive [66]. Increases in prescriptions may take likewise reflected unintended consequences of advancement for the improved treatment of astute and chronic pain in the 1990s, which resulted in regulatory changes requiring the cess of pain as the '5th vital sign'.

Formulations of opioids also play a role in opioid misuse. Standard opioid pills can be crushed to attain a more than rapid effect via routes of administration such as intranasal or intravenous [67]. Despite the lack of sufficient supporting bear witness for the efficacy of abuse-deterrent drugs in preventing misuse, the United States Nutrient and Drug Administration has supported the evolution of such types of prescription opioids to address the growth in opioid-related abuse and deaths [68, 69]. The misconception that abuse-deterrent opioids are a panacea dangerously marks the issue as a pharmaceutical trouble rather than a complex one integrated by biological, psychological and social challenges [67]. Furthermore, abuse-deterrent opioids do non solve the long-standing problem of heroin and other illicitly produced opioids.

The illicit market is another significant source of misused opioids. Heroin is cheap and widely bachelor in about regions in the United States. Furthermore, in that location is a big online opioid market place, which enables customers to purchase unregulated opioids from the web [70, 71]. The increased availability of highly potent synthetic opioids, such as fentanyl and fentanyl analogues, has contributed to the dramatic increase in rates of overdose deaths since 2015 [xix].

At that place has been substantial geographical variation in opioid misuse and overdose, which may exist attributable to a range of factors [72]. Not-metropolitan areas are known to have higher rates of opioid prescribing [73], perhaps because the rural population disproportionately consists of older adults and people employed in physically enervating jobs who may exist peculiarly susceptible to pain-related conditions [74,75,76,77]. Overdose deaths are more prevalent in not-metropolitan areas relative to urban areas [78].

Workplaces and schools are also important settings where individuals spend significant time. Some careers take particularly high rates of opioid misuse and are typically those characterised by demanding physical labour and/or easy access to opioids; individuals involved with construction occupations endure from the highest rate of opioid overdose [79]. Schools are likewise an important setting, given that adolescence is a meaning risk period and diversion of medication is common in this group [80].

Customs norms with respect to alcohol, tobacco and drug use can besides impact the likelihood of initiation of substance misuse [72, 81]. Finally, drug disposal and drove sites tin potentially deter misuse and discourage opioid diversion amongst patients' friends and family by restricting the available supply in households and communities [44].

Similarly, the availability and admission to handling are crucial for both the adequate management of health and mental wellness conditions that increase risks for opioid misuse (due east.g. hurting, psychiatric disorders) and for the effective treatment of OUD [82]. Despite ample prove about effective medications for the treatment of OUD [83, 84], they remain widely underutilised in the United States [85, 86] due to misperceptions nigh the efficacy of medications [87], policy and regulatory barriers [88], and lack of admission to addiction experts [89, 90], amongst others. Furthermore, access to care, and to prove-based care, varies across regions. The availability of high-quality care is as well impacted by societal factors (see beneath). OUD is associated with high rates of relapse and the type of care received has substantial implications for outcomes [91, 92].

Societal level

The major risk factors of opioid misuse are shaped by the larger social context, which encompass opioid supply and demand, government regulations, economic weather and unemployment rates, elements of the media, social stigma, bigotry and prejudice, advertising campaigns, educational campaigns, and police enforcement.

The market place economy of opioids is altered by the fluctuations in a drug'due south supply and demand. A tremendous increase in the supply and availability of opioids arose from the over-prescription, diversion and redistribution of the pills to family, friends and/or co-workers. This was exacerbated by pharmaceutical companies' extensive legal advertising tactics, which tin can lower consumers' perception of the risks of opioids and increase their knowledge on prescription drug availability [93, 94]. Over time, the epidemic intensified as illicit opioids flooded the market place and heroin became inexpensive [82, 95] — heroin is just a third of its price in the 1990s and remains cheaper than opioid prescriptions [96]. Indeed, over fourscore% of people who initiate heroin employ first started opioid utilize with prescription opioids [97]; cost is 1 of the near commonly reported reasons for this transition [98]. Opioid supply can be managed through reduced prescribing or increased apply of misuse-deterrent formulations, but these efforts can be challenged by unintended, short-term negative consequences. In particular, the decreased availability of prescription opioid analgesics tin lead to increases in the employ of illicitly produced opioids such equally heroin [67].

Government programmes and regulations related to opioids may accept many forms such as drug scheduling through the Drug Enforcement Agency, regulation of opioid prescribing practices (east.g. use of Prescription Drug Monitoring Programs; PDMPs) [99] and Medicare/Medicaid regulations. Data support the potential value of certain policies such as Adept Samaritan laws [100], naloxone access legislation [101], and PDMP requirements [102]. Importantly, these dissimilar policies target different elements of the opioid crisis (eastward.g. overdose fatalities, prescribing practices). Regime regulations too have implications for treatment availability, every bit federal and state governments regulate accreditation and licensing requirements as well equally elements of training and service provision. For instance, the Drug Addiction Handling Act of 2000 requires that prescribers consummate boosted grooming to prescribe or manipulate buprenorphine. Likewise, government regulations require that methadone is only dispensed in licensed opioid handling programmes and cannot be used for the treatment of OUD in primary care, unlike in other countries.

The number of people who accept health insurance coverage varies past state and has implications for access to OUD handling. Medicaid expansion has played a significant part in access to medication for OUD; states that elected to expand Medicaid as function of the Affordable Care Deed had a more than than four-fold higher increase in prescribing of effective medications for OUD (specifically buprenorphine and naltrexone) relative to non-expansion states [103]. In addition to their contributions to the opioid supply, payer policies as well impact access to treatment for pain, psychiatric illness and OUD. For example, prior authority for buprenorphine prescribing has been presented equally a strategy for reducing diversion or other adverse events; however, this tin also present a meaning bulwark to care [104].

Social stigma, the misconception of substance misuse as a by-product of weak willpower and moral corruption, is a significant barrier to seeking help for opioid misuse [3, 49, 105]. Likewise, cultural and social behavior communication via media and social media can be either harmful (e.g. influencing an increment in substance use) [106, 107] or protective (eastward.g. increment public sensation nigh opioids and their potential harms).

The rise in 'deaths of despair' (typically referring to overdose and suicide fatalities) betwixt 1999 and 2015 has been linked to poor economic atmospheric condition [82, 108]. During macroeconomic slumps, every pct point increase in unemployment saw a iii.6% rising in opioid death rates and emergency visits. The fall in the employment rate resulted in lower life satisfaction and higher drug employ among the population [109, 110]. A recent working paper from the National Agency of Economic Research concluded that ten% of the rising in opioid-related deaths could be explained by recessions [111]. Even so, macroeconomic impacts on drug use are complex due to the many variables affected by poor economical conditions (e.k. drug prices, incomes, employment, etc.) [112].

Law enforcement and the criminal justice systems are other pregnant components of the response to the opioid crunch. Law enforcement (forth with other emergency responder groups) has been increasingly involved in overdose-rescue efforts. Some departments accept expanded these efforts to include linkage to treatment and other supports. Law enforcement also plays a function in policing of the illicit opioid supply [113]. Finally, opioids are controlled substances that conduct meaning criminal penalties for possession and distribution. Substance use disorders are common among incarcerated people and release from prison is associated with a significantly heightened take a chance for fatal overdose [114]. Racial and ethnic minorities are disproportionately affected by the criminalisation of substance apply, rather than a public health approach. Additionally, those recently released from prison were more likely to die from overdose than those who did not face the law enforcement [82, 115].

Conclusion

The primary goal of this article was to emphasise that the opioid crisis is a multi-faceted and ever-evolving outcome, which requires the consideration of numerous interacting factors in developing interventions and evaluating their effectiveness. Although much of our focus in this paper is on contempo findings and trends, information technology is essential to note that the devastating bear upon of opioid misuse and OUD has been ongoing for decades. The complex and interacting contributors have evolved over time, yet many have been longstanding across each of these levels (east.m. individual, community). These factors intersect with several disparate stakeholder groups, including healthcare providers, government and regulatory agencies, insurers, and law enforcement and criminal justice, amongst others.

Although nosotros have organised our framework according to the individual, interpersonal, customs and social club contexts, we also recognise that at that place is substantial interconnectedness amidst these contexts. For example, access to opioids — a substantial contributor of likelihood of use — cuts across each of these contexts, including the individual (e.one thousand. presence of a pain condition), interpersonal (due east.thou. access to opioids from family or friends), community (eastward.g. availability of drug disposal resources) and guild (east.chiliad. PDMP laws). The ultimate utility of this framework is to utilise it to investigate the complex and multi-directional links amidst the factors that contribute to the ongoing epidemic.

The development of constructive opioid prevention and treatment interventions requires a broad analysis of the factors that ascend from multiple contexts (individual, interpersonal, customs and society). We conceptualised this complex system using the social-ecological framework presented in Fig. 1. As research continues to evolve on these factors and their contribution to the opioid epidemic, this framework tin be farther refined. The framework is also intended to provide context for the generation of testable hypotheses most these factors, their interaction and the impact of treatment or policy levers at each level on the opioid epidemic.

Availability of data and materials

Not applicable.

Abbreviations

OUD:

Opioid use disorder

PDMP:

Prescription Drug Monitoring Program

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Acknowledgements

Nosotros would like to thank Miriam Boeri, Erin Stringfellow, Wayne Wakeland and Scott Weiner who provided constructive feedback on before versions of this article.

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Affiliations

  1. Harvard Medical School, Harvard University, Boston, MA, The states of America

    Mohammad S. Jalali & R. Kathryn McHugh

  2. Institute for Technology Assessment, Massachusetts Full general Hospital, 101 Merrimac St, Suite 1010, Room 1032, Boston, MA, 02114, United states of america

    Mohammad Southward. Jalali & Rachael C. Hwang

  3. Grayken Heart for Addiction, Boston Medical Center, Boston, MA, U.s.a.

    Michael Botticelli

  4. T.H. Chan School of Public Wellness, Harvard University, Boston, MA, United States of America

    Howard M. Koh

  5. Harvard Kennedy School, Harvard University, Cambridge, MA, U.s.a.

    Howard K. Koh

  6. Division of Alcohol and Drug Abuse, McLean Infirmary, Belmont, MA, Us of America

    R. Kathryn McHugh

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Conceptualisation and design: MSJ, RKM; Writing the first draft: MSJ, RCH, and RKM; Discussion, disquisitional review, and writing: MSJ, MB, RCH, HKK, and RKM. All authors read and canonical the final manuscript.

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Correspondence to Mohammad S. Jalali.

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Jalali, M.S., Botticelli, M., Hwang, R.C. et al. The opioid crisis: a contextual, social-ecological framework. Wellness Res Policy Sys 18, 87 (2020). https://doi.org/10.1186/s12961-020-00596-8

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Keywords

  • opioids
  • opioid utilize disorder
  • social-ecological framework

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