Plan de Medios

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.