Examining factors precipitating substance abuse, from America's rural to urban communities.
There are numerous external factors that affect an individual’s drug use habits, such as employment rates, current drugs on the market, and the quality and accessibility of local healthcare. But many people who use drugs (PWUD) perceive their addiction as a personal failing—and, if they seek help, all too often encounter a healthcare system that reinforces their perception. To fight this stigma and offer better care, more clinicians are seeking ways to tailor addiction treatment to each community they serve.
Marissa Abram ’08, PhD ’17, assistant professor in Adelphi’s College of Nursing and Public Health, wanted to understand how local conditions can shape addiction, so she decided to look to a singularly controlled setting: Alaska. “The state has small, diverse populations within an expansive geographic region, as well as a climate that’s very different from the rest of the country,” she explained. “That makes it a great place to think about different community needs.”
Marissa Abram ’08, PhD ’17, assistant professor in the College of Nursing and Public Health, is a psychiatric-mental health nurse practitioner and a credentialed alcohol and substance abuse counselor. Her research focuses on substance abuse.
Access to healthcare and financial resources are important social determinants of health. In an effort to understand addiction’s relationship with unemployment and median income in Alaska, Dr. Abram teamed up with epidemiologist David Parker, PhD, professor, and Lauren Lessard, PhD, and Jennifer Meyer, PhD, assistant professors, all at the University of Alaska Anchorage, to compare results from national and local surveys on drug use. Their findings were published in the paper “Twenty Years of Addiction and Mental Illness in Alaska: Using the National Survey on Drug Use and Health to Understand Addiction in a Low Population and Rural State” in the Journal of Community Health (May 2022).1
Ultimately, they found that median income was more frequently linked to addiction than unemployment. Still, Dr. Abram stresses that this finding should only be treated as a baseline and researchers must partner with communities to truly gain an understanding of what is needed. “We need to always remember that there’s really no one-size-fits-all intervention and treatment strategy,” she said.
Dr. Abram’s colleague Adelya Urmanche, PhD ’22, adjunct professor in the Master’s in Psychology Program, has also been investigating ways to design community-specific addiction treatment. For her paper “Fentanyl preference among people who use opioids in New York City” (Drug and Alcohol Dependence, August 2022),2 she and her co-authors interviewed 22 PWUD in New York City who said they prefer to use nonpharmaceutical fentanyl (NPF), an analgesic that can be a hundred times stronger than morphine. Dr. Urmanche then analyzed what PWUD had to say about their own experiences with NPF, particularly how they navigated its benefits and risks.
Adelya Urmanche, PhD ’22, is a postdoctoral research fellow at Mount Sinai Beth Israel Medical Center and adjunct faculty at the Gordon F. Derner School of Psychology whose clinical and research work focuses on psychotherapy processes and provider training that could improve addiction treatment outcome and retention.
Within this sample group, Dr. Urmanche found that PWUD preferred NPF for a variety of reasons, including individual needs, drug use patterns and previous experiences with drugs. “Many commented on NPF’s superior analgesic effects, perceived longer effects and lower cost,” she said. “For others, it was not so much a consideration of ‘benefits,’ but of what they could get on the market. Still other participants suggested that NPF resulted in an increased tolerance to opioids, thus ‘locking’ them into continued use of NPF.”
Unfortunately, Dr. Urmanche added, some people assume PWUD turn to NPF because they want the “hard stuff.” This assumption is not only inaccurate, but also further stigmatizes a vulnerable population already working hard to stay safe in an increasingly dangerous environment. In 2020, New York City registered more than 2,000 overdose deaths. NPF was implicated in 77 percent of them—a number only set to rise as NPF appears in more and more counterfeit opiate pills, cocaine and benzodiazepines.
“It’s not only NPF that kills, though,” Dr. Urmanche said. “It’s also stigma. That’s usually more of a problem than access.” Many participants in the study reported difficulty finding other people who could help keep them safe while they used NPF, for instance.
According to Dr. Urmanche, these findings reinforce the importance of offering client-centered care to PWUD. “People who use drugs are quite thoughtful and deliberate about their behaviors and, as many of us do, value product consistency and physiological comfort,” she said. “They use drugs for different reasons, in different contexts, with different resources, and have different thresholds for risk. Providers sometimes forget to stay curious about those things. But we must be better at understanding and incorporating PWUD’s experiences to create a treatment system that meets their individual needs.”
A Safer Way to Use Drugs
In the 1990s, clinicians began experimenting with a new way of treating PWUD. Rather than treat drug use as a behavior that must be stopped, they instead created spaces where drugs could be used in relative safety: supervised drug consumption sites.
“A supervised drug consumption site is a safe, nonjudgmental space where an individual experiencing addiction can use their substances,” Dr. Abram explained. “When people hear that, sometimes they have a visceral reaction, but there’s actually a lot of evidence that supervised consumption sites save lives.”
In “Supervised drug consumption sites: A health-based approach or enabling drug use?” (Journal of Clinical Nursing, December 2022), co-authored with colleagues from the Nursing School of Lisbon in Portugal and Deakin University in Australia, Dr. Abram calls for an expansion of these spaces to encourage more people to use drugs safely. ¹ “The thing to keep in mind is that these sites provide medical and psychiatric care,” she said. “If people don’t get care until they’re in the emergency room, they’re much more likely to be stigmatized, including by healthcare professionals.”
There’s also evidence that these sites can help PWUD improve their overall health. Once they’ve been able to access healthcare without judgment and ostracization, they may feel safer pursuing medical treatment, substance rehabilitation and psychiatric care they might otherwise avoid. “Healthcare professionals need to look past our own perceptions and our own biases,” Dr. Abram concludes. “If we’re more open to the experiences of others, then we can expand treatment access, increase bridges to care and ensure better patient outcomes.”
¹Abram, M.D., et al. “Twenty Years of Addiction and Mental Illness in Alaska: Using the National Survey on Drug Use and Health to Understand Addiction in a Low Population and Rural State.” Journal of Community Health, vol. 47, August 2022, pp. 680-686.
²Urmanche, Adelya A., et al. “Fentanyl preference among people who use opioids in New York City.” Drug and Alcohol Dependence, vol. 237, 1 August 2022.
³Abram, Marissa D., et al. “Supervised drug consumption sites: A health-based approach or enabling drug use?” Journal of Clinical Nursing, vol. 32, issue 7-8, April 2023, pp. e6-e8.