Substance Use Disorders
Substance use disorders affect more than 23 million Americans. Over the last 20 years, the US has experienced a five-fold increase in drug-related deaths and the overdose epidemic continues to grow with an estimated 86,000 fatal overdoses observed in 2019. Without addressing root causes, the epidemic is likely to persist without abatement into the next phase of its evolution.
As such, the Center for Addiction Research and Effective Solutions (AIR CARES) applies a social determinants of health (SDoH) framework to its work. An approach grounded by SDoH recognizes that the most influential points of intervention for health outcomes are often upstream of individual-level factors. While individual behavior may be part of the path to health, the context in which individuals make health-related choices dictates their ability to act on knowledge, attitudes, and beliefs.
Expanding the narrow focus of the traditional biomedical model for addressing substance use disorder means considering how employment, housing, social and community context, education, and access to quality healthcare play a role in prevention, treatment, and recovery.
Employment interventions have a positive impact on addiction treatment outcomes and employment can be an effective addiction prevention and recovery strategy. Research has also demonstrated at the community level the association between unemployment and economic downturn and increases in substance use and overdose deaths. Increasing employment opportunities for people in treatment or recovery is particularly important for communities experiencing dual dilemmas of unemployment and addiction. Due to historic and systemic issues in the U.S., minorities and other groups are vulnerable to higher rates of unemployment during periods of economic downturn and have fewer safety nets to overcome the strain.
Through leveraging AIR's experience in workforce development, and evidence-based design of tailored interventions and technical assistance, AIR CARES works to address barriers to employment for people with current or history of substance use, and design human capital solutions to help employers recruit and retain talent, with a macro-level lens toward improving the social and economic well-being of workers and the communities they live in.
The Fair Housing Act forbids discrimination on the basis of disability (of which addiction qualifies under the ADA); yet some local public housing authorities and private landlords continue to use the discretion afforded to them by federal housing policy to target people with a history of substance use through punitive eligibility criteria and eviction triggers. One collateral consequence of a law enforcement-focused response to a medical condition is that criminal justice involvement creates additional barriers to securing stable housing following release from prison or jail. Justice-involved individuals are almost 10 times as likely to experience homelessness than those without criminal justice involvement. Innovative housing models, such as Housing First, demonstrate that housing can improve substance use disorder outcomes. Without housing, recovery can be a challenge. Adults who experience homelessness are nine times more likely to die from overdose than those who are stably housed.
CARES draws on AIR’s rich expertise on homelessness and housing to support work that is grounded in the belief that people who use drugs that are experiencing homelessness deserve housing and are worthy of dignity and housing is as a critical first step toward recovery from substance use disorder.
Social and Community Context
A focus on social and community context is needed to improve the psychosocial, intergenerational, and interpersonal connections needed to prevent and recover from substance use disorder. Effective solutions must act as a counterbalance to the historic disinvestment and traumatization of many communities. Stigma and social norms related to drugs drive policy and, in turn, punitive policies drive stigma. CARES supports communities through work that is driven by respect and humility, builds community capacity and sustainable relationships, empowers the people whose lives are impacted by the work, improves health, restores justice, and contributes to knowledge and social change.
AIR’s work spans the learning life course—from pre-K to postsecondary education, career readiness, and adult education—and focuses on a wide range of topics, including STEM, social and emotional learning, and state and federal education policies. AIR CARES recognizes that the education system has a role in preventing and/or delaying problematic alcohol and drug use as well as connecting youth to care who may need behavioral health services for mental health and substance use needs. Schools also serve as a first line of defense for youth experiencing trauma, which—left unaddressed—has long-term implications for addiction, mental health, and other chronic conditions.
Schools have a role in addressing the intergenerational factors related to addiction. Youth with at least one adverse childhood experience (ACE)—which include insufficient access to basic necessities, violence, parental incarceration, parents with substance use disorder—are two to four times more likely to begin alcohol and drug use at an early age, compared to youth without adverse childhood experiences. ACEs are tied to a number of health outcomes, demonstrating a dose response. Having five or more ACEs is associated with a 10-fold risk for addiction. For vulnerable families, schools are a safety net that can directly or indirectly provide resources that decrease addiction risk for children and their families.
Lack of access to quality education and its neighborhood correlates lead to marginalization and places individuals at higher risk for addiction. Providing quality education in safe and supportive learning environments is a key prevention strategy for addiction. When we are able to prepare youth for learning and keep them engaged, helping them to achieve age-specific educational and social milestones, we lower the risk of addiction.
Access to Quality Healthcare
AIR CARES brings extensive expertise in providing training and technical assistance to expand access to and quality of evidence-based addiction treatment. AIR CARES understands that there are a variety of challenges in ensuring that people get timely access to quality, accessible, and appropriate services, including but not limited to:
- Historical separation of addiction treatment and medical services;
- Lack of addiction training in schools of nursing, medicine, social work, and other health professions;
- Stigma associated with treating addiction and with the use of medications for addiction treatment;
- Cultural competence in medicine;
- Poor infrastructure to allow delivery of integrated services; and
- Reimbursement limitations.
AIR CARES uses a tailored approach to address these challenges and ensure successful adoption, implementation, and sustainability of addiction treatment services that center the work on the context in which services are delivered, meeting the needs of the people served, and workforce development best practices.