Biopsychosocial Factors
The opioid epidemic has opened our eyes to the complicated and all-encompassing reality of addiction. While it has been uncovered that pharmaceutical companies played the primary role in pushing opioids into every community in America, other factors contribute to what keeps opioid users using. Some terms that will be used frequently include OUD, which stands for Opioid Use Disorder. Opioid use disorder can be described as a chronic disorder where individuals misuse prescribed opioids or obtain opioids in an illicit way (Stranget al., 2020). Opioids are a type of prescription drug that is often prescribed to treat pain, such as Fentanyl, Vicodin, or Oxycontin. Opioids are also synonymous with street drugs such as Heroin (Stranget et al., 2020). Biopsychosocial factors are essential to understanding the root of addiction and how to treat it. To summarize the importance of the "person-in-environment" or biopsychosocial perspective, Turner states that a person's biopsychosocial factors are just as dynamic and complicated as themselves (Turner, 2017). Where in the past, drugs may have been confined to low-income neighborhoods, opioids seeped into middle-class and upper-middle-class neighborhoods, setting off the alarm that something needed to be done. The documentary "Chasing Heroin" by PBS emphasizes the interplay of substance users' lives and their families, community, and environmental factors. Addiction is a disease that individuals and their families deal with for the rest of their lives.
Similarities among opioid users are difficult to find when you see that these drugs permeate every community in every socio-economic group, but there are some that exist. In the Documentary Chasing Heroin, there were several individuals with an injury or chronic pain whom a doctor, in turn, prescribed large doses of opioids. Another situation was an underlying psychological problem like anxiety or depression, and the individual turned to self-medicating at a young age with drugs and alcohol. There are also situational or environmental factors, like living in a low-income neighborhood full of crime and drugs. Overall, there needs to be an understanding that there are many ways one can become addicted to opiates.
Biological
Biological factors include an individual's physical health, genetic predisposition, neurochemistry, and disabilities (Hall, 2022). These factors can play a large part in an individual's opioid use but are only one part of the equation. In the documentary Chasing Heroin, there is an individual named Johnny who was able to stay sober for around nine months and eventually relapsed. Johnny talks about his childhood and his mother's own addiction and finding her dead with a needle sticking out of her arm (Gavina, 2016). This could imply that Johnny had a biological predisposition to addiction carried down from his mother.
Biologically, the impacts of dope sickness can be deadly if left untreated. Death, seizures, infection, nausea, vomiting, and confusion can be some symptoms of withdrawal. It is now widely known that once a user is hooked, the outcome of using is no longer enjoyable but rather a means not to feel sick (Jackson, 2004). Methadone and Suboxone are medications that have been used to treat those with a biological addiction to opioids as a way to keep them from abusing prescription pills or other street drugs by curbing cravings. Both are typically administered to patients daily and are highly regulated. The documentary Chasing Heroin emphasizes that addiction needs to be treated as a chronic illness and that users need Suboxone and methadone just like diabetics need insulin (Gavina, 2016).
Social & Environmental
Social and environmental factors include peer relationships, family circumstances, cultural traditions, social support, community relationships, and education (Hall, 2022). Furthering the analysis of the individual named Johnny, he talks about when he first started using it as the time that he was going through a divorce with his wife. He started using hard drugs, and things spiraled from there (Gavina, 2016). This is an example of a social factor that led to Johnny's opioid use. Environmental factors can also look like a person with OUD who is unhoused and forced to go to a shelter that houses others suffering from OUD or other types of substance abuse. Being in an environment where others are using substances can contribute to an individual's relapse, which they otherwise may not have chosen to use (Bascou et al., 2022).
It may be harder for individuals in rural communities to access treatment and resources than those living in bigger cities. The documentary Chasing Heroin showed a program in Seattle, LEAD, or Law Enforcement Assisted Diversion, that not only fostered a good relationship between opioid users and law enforcement but kept users out of jail. Instead of arresting users, the goal was to get them into treatment on their terms, prevent overdoses and theft, and overall provide a harm reduction method (Gavina, 2016). They also depicted the process of trying to get more clinics in communities that need them and the pushback they received from residents living there. There is a "not in my backyard" attitude when it comes to treatment centers that are harmful to those suffering from opioid addiction.
Psychological
According to The Shame Spiral of Addiction: Negative Self-Conscious Emotion and Substance Use, the psychological feeling of guilt and shame creates obstacles in decreasing substance use. Shame is the negative view of self and guilt, which can be described as the negative view of a behavior (Batchelder et al., 2022). Shame came up in the documentary as well as in several journals related to opioid abuse, and it seems to be a paralyzing feeling that stops us from talking about the problem. In the documentary Chasing Heroin, Sam Quinones stated that the Opioid epidemic is "The quietest epidemic" due to the shame that not only the users feel but also the families, and this prevents them from talking about it. People are suffering in silence due to the stigma. There is a "shame addiction cycle" (Batchelder et al., 2022) that is used to describe the cycle that individuals with OUD use to avoid addressing their feelings or emotions, then results in the sense of shame because they used substances (Batchelder et al., 2022). Essentially, shame keeps individuals stuck in a pattern that results in relapse.
Psychological conditions such as anxiety, depression, or serious mental illnesses such as bipolar disorder and schizophrenia can cause an individual to "self-medicate," which can lead to addiction. In Chasing Heroin, there was a young woman named Mara who started experimenting with drugs and alcohol at fourteen years old due to underlying feelings of anxiety and depression. This experimentation ultimately led to heroin use at the age of sixteen. Like many others, Mara was clean for a period of time before relapsing and overdosing, resulting in her death (Gavina, 2016).
Familial, Group & Community Factors
Familial Factors
The things we learn from our family of origin are most often what shape the way we see and interact with the world. Turner highlights the importance of familial factors by stating that no matter who the intervention is for in the family system, every single member is affected as well as the "family patterns, equilibrium, and changes." (Page 245) Every change or incident that occurs can have a profound impact on the way that a family operates or the mental health of the members (Turner, 2017). Depending on the quality of the relationships between family members, the individual struggling with opioid use disorder can be positively or negatively impacted.
Group Factors
The company you keep can often influence the types of behaviors you participate in. In the Chasing Heroin documentary, we saw Carrie describe how she started dealing drugs when she was in the middle of active addiction. She was involved in this group that was surrounded by drug dealers, and eventually, she herself became a drug dealer to pay for her habit. She also described how she was living at home; once a diligent housewife in a nice neighborhood, she found herself living with others suffering from OUD in a house full of animal feces, trash, and drugs. The documentary even referred to Carrie as the "unassuming housewife ."A study done from 2017-2018 found that race/ethnicity is actually not a strong indicator or predictor of an individual's substance use but rather that person's access to drugs and usage by family or their group of friends (Montiel et al., 2020).
Community Factors
The views and attitudes of a community can shape the treatment options and resources available to opioid users. Is the community open to suboxone or methadone clinics being open? The relationship between the police and active opioid users also becomes essential to outcomes. Chaos Theory acknowledges the often unpredictable world we live in and the consequences of that reality (Turner, 2017). Social work is a multilayered profession that deals with the chaotic nature of people's lives and seeks to understand that person in their environment and seek solutions or skills so that person can thrive. According to Turner, “Chaos theory offers help in understanding human relationships and organizations, but it also demands that we abandon our obsession with control.” (Page 25) Enforcement agencies are based on control, and officers are in communities to control crime, which can often become counter-productive in the treatment of opioid addiction. It has been shown that arresting substance users does not stop them from relapsing once their jail or prison time is over, and an alternative that has been created is drug courts (Gavina, 2016). Drug courts are meant to prevent substance users from going to jail and instead focus on their access to treatment and resources. The issue that seems to arise from this model is that relapse is almost guaranteed throughout the recovery process, and if an individual does not complete drug court, they typically will automatically be charged as guilty and left to face those legal consequences. (Gavina, 2016). This drug court model can be seen through the lens of Chaos theory as an attempt to control the chaos of individuals with addiction. Turner suggests that giving clients the tools to come up with new versions of their stories that create growth rather than focusing on the OUD can empower individuals and provide more positive outcomes (Turner, 2017). A limitation of chaos theory is that it does not provide a framework to predict the outcomes of treatment (Turner, 2017). Public stigma turns into the internalized stigma.
Intersectionality
There are several intersectional factors that affect how individuals experience their opioid use disorder. Geographical location, race, socio-economic status, and gender all have an effect on an individual's recovery from OUD. One study found that African-American men and women with OUD are arrested at a much higher rate than their white counterparts (Corrigan & Schomenis, 2022). Another study titled Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States found that treatment options were not equal for all, showing that "facilities providing methadone were significantly more likely to be located in highly segregated African American and Hispanic/Latino counties, while facilities providing buprenorphine were significantly more likely to be located in highly segregated white counties." (Page 8). They promoted the fact that both medicines should be available to every person with OUD at every treatment facility due to the trial-and-error nature of using medications to treat OUD (Goedel et al., 2020).
Social Work Paradigm
Social work values are ideals that we use as a framework to guide our practice and facilitate the best outcomes. It’s imperative for social workers to uphold the integrity, dignity, and worth of the person when interfacing with populations suffering from OUD. Harm reduction has been proven to increase positive outcomes for opioid users (Bascou et al., 2022). As with other disciplines, focusing on prevention and harm reduction tends to result in increasingly positive results (Bascou et al., 2022). The way social workers interact with and treat clients suffering from OUD can change or alter the success of the treatment process.
Dignity & Worth of the Person
Part of upholding the dignity and worth of the person in the situation of a person using opioids we need to reduce the stigma. The study Reducing the stigma surrounding opioid use disorder: evaluating an opioid overdose prevention training program applied to a diverse population found that their results showed that prevention was effective in treating OUD. Not only does it touch on the importance of reducing the stigma but also the biopsychosocial component. The main point of the study was to reduce the stigma attached to opioid prevention programs by providing education on how and why they work in reducing overdoses (Bascou et al., 2022). I think we can help reduce negative outcomes by educating the population on addiction using the disease model. This promotes the dignity and worth of the person by recognizing that social workers need to meet the client where they are and that individuals with OUD are, in fact suffering from a disease that needs appropriate treatment (Bascou et al., 2022). This is shown in the documentary Chasing Heroin with the LEAD program, which seeks to avoid arresting individuals with OUD and instead provide them with resources, options for treatment, or harm reduction, such as needle exchanges (Gavina, 2016).
Importance of Human Relationships
Part of social work ethics includes recognizing the importance of human relationships and their ability to implement positive change in people's lives. This extends to the population of people experiencing OUD. By strengthening the relationship between individuals with OUD and the police, community, and their families, we are improving their chances of recovery. Relationships can also be detrimental to recovery, as we see in the Chasing Heroin documentary when Carrie describes a time when she was in recovery, but she ran into an old friend. This friend asked her to get coffee, and Carrie agreed despite knowing this friend was in active addiction. Unfortunately, Carrie ended up relapsing when they used opioids together (Gavina, 2016).
Overall, the research confirms the importance of the biopsychosocial perspective in treating individuals with OUD. Family, community and group factors play a large role in the stigmatization or de-stigmatization of those suffering from OUD. The focus should be on prevention and harm reduction, and we should be staying away from a criminalized model. Social workers need to promote holistic, respectful, and equitable treatment. Providing individuals suffering from OUD with a respectful, safe, and nonjudgemental space is imperative to de-stigmatizing this disease and opening the opportunity for more research.
References
Bascou, N. A., Haslund-Gourley, B., Amber-Monta, K., Samson, K., Goss, N., Meredith, D., Friedman, A., Needleman, A., Kumar, V. K., & Fischer, B. D. (2022). Reducing the stigma surrounding opioid use disorder: evaluating an opioid overdose prevention training program applied to a diverse population. Harm Reduction Journal, 19. https://doi.org/10.1186/s12954-022-00589-6
David A. Wiss. (2019). A Biopsychosocial Overview of the Opioid Crisis: Considering Nutrition and Gastrointestinal Health. Frontiers in Public Health, p. 7. https://doi.org/10.3389/fpubh.2019.00193
Shepherd, M. E. (2022). The politics of pain: Medicaid expansion, the ACA and the opioid epidemic. Journal of Public Policy, https://doi.org/10.1017/S0143814X21000192
Turner, Francis J., et al. “The Psychosocial Framework of Social Work Practice.” Social Work Treatment: Interlocking Theoretical Approaches, OXFORD University Press, 2017, pp. 411–419.
Gavina, Marcela. Chasing Heroin, PBS, February 23, 2016, https://www.pbs.org/wgbh/frontline/documentary/chasing-heroin/.
Batchelder AW, Glynn TR, Moskowitz JT, et al. The shame spiral of addiction: Negative self-conscious emotion and substance use. PLoS ONE. 2022;17(3):1-17. doi:10.1371/journal.pone.0265480
Hall, T. (2022). Biopsychosocial Perspective and Resiliency [PowerPoint slides]. College of Social Work, Bridgewater State University.
Montiel Ishino, F.A., McNab, P.R., Gilreath, T., et al. A comprehensive multivariate model of biopsychosocial factors associated with opioid misuse and use disorder in a 2017–2018 United States national survey. BMC Public Health, (2020). https://doi.org/10.1186/s12889-020-09856-2
Strang, J., Volkow, N.D., Degenhardt, L. et al. Opioid use disorder. Nat Rev Dis Primers (2020). https://doi.org/10.1038/s41572-019-0137-5
Krista L. Scorsone, Emily A. Haozous, Leslie Hayes & Kim J. Cox (2021) Ending the Chase: Experiences of Rural Individuals with Opioid Use Disorder, Substance Use & Misuse
Goedel WC, Shapiro A, Cerdá M, Tsai JW, Hadland SE, Marshall BDL. Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States. JAMA Netw Open. (2020)
