The War on Drugs: The Social Determinants of Addiction

Written by Aysha Umar

Dr. Gabor Maté: Early Childhood Trauma and Addiction
In his book In the Realm of the Hungry Ghosts: Close Encounters with Addiction, Dr. Gabor Maté (M.D) describes the Buddhist wheel of life - the mandala, which circles through six realms. Each realm consists of characters which represent the various aspects of human existence. One realm, the ‘hungry ghost’ realm, is marked by the constant search for an external desire, temporary fulfillment for our yearning for something greater than reality. 
The emptiness depicted in this realm is eternal, because the substances, objects, and desires we believe will fulfill it are not what we are looking for. However, as long as one stays in the hungry ghost mode, they will remain insatiable, never knowing what they are truly searching for. 
This is the domain of addiction. 
The drug addicted brain does not function in the same way as a non-addicted brain and scientific literature unanimously views addiction as a chronic brain condition. This view alone should be reason enough to deter societal victim blaming of an individual suffering from addiction. Evidence revealing that the brain functions differently in drug-addicted individuals emphasizes the idea that an addict’s ability to “choose” is significantly impaired, and thus has critical implications in treatment. Therefore, when health care systems continue to view and treat addiction as an acute disorder, if they attempt to treat it at all, is problematic.
There are several factors that go into substance abuse and drug addiction, as drugs alone cannot turn anyone into an addict. Dr. Gabor Maté highlights the importance of (1) pre-existing vulnerability, (2) a drug with addictive potential, and (3) stress, as three main precursors for determining the course of drug addiction.
Dr. Gabor Maté worked as a psychiatrist in Vancouver’s Downtown Eastside (DTES) neighbourhood. The DTES has been designated “the poorest postal code” in Canada; it is notorious for high rates of drug use, poverty, crime, communicable diseases, and mental illness. In the novel Fighting for Space by Travis Lupick, which focuses on the DTES, Dr. Gabor Maté emphasizes childhood trauma as an important social determinant of health leading to pre-existing vulnerability for addiction.
Dr. Gabor Maté began to notice that all of his patients who struggled with addiction were traumatized as children—their brains were not functioning abnormally; rather, they were responding in a normal way to their personal, abnormal circumstances. Their childhood experiences resulted in the physiological alteration of their brains and in the long-term, made the brain significantly more susceptible to addiction. He states individuals addicted to drugs are simply attempting to suppress childhood memories. The primary stressor keeping these individuals mired in addiction is in fact the prohibition of these drugs.
Dr. Bruce Alexander: Rat Park
In 1979, Avram Goldstein wrote that if heroin were made available to everyone, with no social pressure to discourage its use, then everyone would become a heroin addict. This started the war on drugs by the U.S. President, Richard Nixon. However, in 1978, Dr. Bruce Alexander at Simon Fraser University conducted his “rat park” study.  Alongside his colleagues, he devised a study to test whether different living conditions could affect an animal's decision to inject themselves with drugs via the press of a button.
First, researchers administered all the rats copious amounts of morphine, where they would press a button to self-administer the drug. The idea was that if drugs themselves resulted in chronic addiction, then no matter which housing condition the rats were confined to – they would remain addicted to the morphine.
Researchers then created two housing conditions for their rats; one in which rats were housed in isolation, and one in which rats were housed in “Rat Park.” Rat Park was a high quality, enriched environment where the animals were given the opportunity to socialize, play, and keep themselves stimulated. Rats in both housing conditions were given the same level of access to morphine.
When the rats were monitored, researchers found that the isolated rats drank significantly more morphine than the rats housed in Rat Park. This suggested to them that housing conditions played an important role in determining the self-administration of these ‘addictive’ drugs. Dr. Alexander and his colleagues believe that for the isolated rats, the morphine served as relief from discomfort caused by the spatial confinement, social isolation, and the stimulus deprivation that they experienced.
When Dr. Alexander attempted to apply this study to human societies, he interviewed Indigenous communities in Canada, living on reserves. Interestingly, he found that nothing like addiction had existed in these Indigenous communities prior to their colonization, nor prior to the destruction of Indigenous culture. These findings highlight how social exclusion and housing instability serve as crucial social determinants of health in the course of developing a drug addiction.
Switzerland: Harm Reduction
In 1994, the Swiss government turned to Heroin-Assisted Treatment (HAT) as a means of combating heroin addiction in place of their typical approach. They allowed heroin users to receive physician-assisted heroin injections for a cheap fee, then funded a research program to evaluate the efficacy of these clinics. 
Contrary to what they had expected, the results were all positive. These studies found that once drug-users realized they had a cheap and reliable source of heroin, the majority turned away from their current lifestyles and improved their health through specialized programs. Many of these users strengthened familial relationships, gained employment, and attempted to stop using heroin.
Heroin use is no longer present in Switzerland’s streets and parks, and drug-related crime has decreased exponentially. Those who still use heroin have improved social and physical well-being, and new cases of heroin use have declined significantly. Most medical risks from drug-addiction can be attributed to the battle between the criminalization of opioids resulting in users purchasing substances from unreliable places, and thus living in poverty with a lack of access to health care services. 
Bridging the Gap
The overdose crisis disproportionately affects vulnerable populations due to the intersectionality between structural inequities (such as poverty, criminalization of drugs, homelessness), and discrimination (such as racism, sexism, prejudice). Overdose deaths are heightened among people of colour, where systemic racism, socio-economic marginalization, and criminalization play a significant role. These factors, alongside housing instability, are crucial determinants of a population's structural vulnerability and are linked with drug-related risks.
Since the Swiss HAT study, several other countries in Europe and North America have implemented similar harm reduction trials and have all demonstrated that HAT is effective, feasible, and safe. These studies have consistently demonstrated strong positive outcomes in populations of high-risk addicts, at least in the short-term.
Harm reduction is an example of an upstream intervention plan (i.e., one that targets the root causes of the disease), and creates health care equity among vulnerable populations.
When we begin to view drug addiction and overdose deaths as a product of structural inequity, it becomes possible to better understand how to prevent these crises through health promotion and harm reduction programs. Additionally, when healthcare professionals begin to treat addiction as a medical issue and move away from victim blaming, it becomes possible to bridge the gap between vulnerable populations and their lack of access to upstream health care services.
 
References
Alexander, B. K., Beyerstein, B. L., Hadaway, P. F., & Coambs, R. B. (1981). Effect of early and later colony housing on oral ingestion of morphine in rats. Pharmacology, Biochemistry and Behavior, 15(4), 571–576. https://doi.org/10.1016/0091-3057(81)90211-2
Fischer, B., Oviedo-Joekes, E., Blanken, P., Haasen, C., Rehm, J., Schechter, M. T., Strang, J., & van den Brink, W. (2007). Heroin-assisted treatment (HAT) a decade later: a brief update on science and politics. Journal of Urban Health, 84(4), 552–562. https://doi.org/10.1007/s11524-007-9198-y
Khan, R., Khazaal, Y., Thorens, G., Zullino, D., & Uchtenhagen, A. (2014). Understanding Swiss Drug Policy Change and the Introduction of Heroin Maintenance Treatment. The Canadian Journal of Addiction, 5(2), 21–22. https://doi.org/10.1097/02024458-201406000-00010
Linden, I. A., Mar, M. Y., Werker, G. R., Jang, K., & Krausz, M. (2013). Research on a Vulnerable Neighborhood—The Vancouver Downtown Eastside from 2001 to 2011. Journal of Urban Health, 90(3), 559–573. https://doi.org/10.1007/s11524-012-9771-x
Lupick, T. (2018). Fighting for space: how a group of drug users transformed one city’s struggle with addiction. Arsenal Pulp Press.
Maté, G. (2018). In the realm of hungry ghosts: close encounters with addiction (Revised edition.). Vintage Canada.
McNeil, R., Fleming, T., Collins, A. B., Czechaczek, S., Mayer, S., & Boyd, J. (2021). Navigating post-eviction drug use amidst a changing drug supply: A spatially-oriented qualitative study of overlapping housing and overdose crises in Vancouver, Canada. Drug and Alcohol Dependence, 222, 108666–108666. https://doi.org/10.1016/j.drugalcdep.2021.108666
Pxhere. [untitled illustration] https://pxhere.com/en/photo/1266315?utm_content=shareClip&utm_medium=referral&utm_source=pxhere
Uchtenhagen, A. (2010). Heroin-assisted treatment in Switzerland: a case study in policy change. Addiction (Abingdon, England),105(1), 29–37. https://doi.org/10.1111/j.1360-0443.2009.02741.x
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World Health Organization. (n.d.). Social Determinants of Health. World Health Organization. https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1. 


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