Opioid-related drug overdose is a leading cause of death and injury in the United States. Both prescription as well as illicit opioids continue to play a major role in the growing opioid epidemic. When we consider individuals who use opioids, some of the social factors described in this post may double as risk factors for infectious disease transmission, including COVID-19. Early studies of Middle East Respiratory syndrome coronavirus (MERS-COV) that emerged in 2012 documented that transmissions and outbreaks have been correlated with healthcare settings.
Recently, experts have called attention to how people who disproportionately suffer from poor access to healthcare, or who experience unstable housing and employment, combined with using (and in particular, injecting) opioids may be at elevated risk for COVID type infections. Research further documents the relationship between social isolation and drug overdose. And not surprisingly, where people live has also been shown to have a major impact on opioid use and overdose. In the case of the latter, data document spatial segregation and social isolation dynamics at the county level or under the rubric of an urban/rural divide. None of this research, due to its timing, addresses the current social isolation dynamics as they are occurring within the context of COVID-19. As previous posts in this series have noted, the pandemic that is unfolding now potentially impacts supply reduction strategies that have been put into place to curtail illicit drug use and other health and social problems. Already, numerous states, including Pennsylvania, have noted surge activity in opioid overdose as a result of government mandated “lockdowns”.
How Do Social Factors Influence Opioid Overdose and Police Response?
I am currently in the process of concluding research with a team on a study that asks questions about how social factors contribute to drug overdose (field data collection was interrupted by human subjects limitations imposed with COVID-19). Over the course of the study, 24 individuals completed a survey concerning their experience with overdose and use as well as access to health-related services; 15 participated in in-depth interviews, where they discussed their experiences with living in the McKeesport and Mon Valley region in addition to their experiences with overdose. Research subjects are drawn from the city of McKeesport, Pennsylvania, a small river city in the Monongahela Valley, located east of Pittsburgh. This community has been hit especially hard by the opioid epidemic, as it lies within the state’s southwest quadrant, where overdose rates are on the rise. Allegheny County, PA. recorded one of the highest overdose mortality rates in the United States from 2008 to 2020, while the city of McKeesport suffered an incidence of fatal overdose twice that of the county. During the course of the study, we modified our survey methods (shifted to online surveys instead of in-person) and added some questions to help explain how social dynamics that contribute to drug overdose might also influence and interact with the social dynamics of COVID-19. Specific COVID-19 questions like: “I believe that the outbreak of COVID-19 may increase my use of alcohol or drugs” and “I believe the outbreak of COVID-19 would make police less willing to help someone who has overdosed.” Online survey efforts yielded an additional 16 survey respondents, bringing the total number surveyed to 44.
Preliminary results indicate that the rapidly evolving social landscape of the pandemic indicate increased risks for overdose as well as COVID-19 infection. Institutional trust of the police, which is already showing signs of deterioration in McKeesport and across the U.S., appears to be another casualty of the pandemic. We note that in this aspect, the pandemic both reveals and exacerbates the vulnerability of certain populations (to drug-related harm as well as structural/institutional harm), even as other groups of substance users may be shielded by new protective factors that accompany such dramatic changes in social context.
The social factor that we find thus far contributes the most to feelings of social isolation is unemployment; more than 70 percent of our subjects were effectively unemployed and unable to work. Many indicated they had given up and were no longer looking for work, while others cited disability, lack of local work opportunities, and struggles with transportation as barriers to employment. Additionally, even in the early stages of the pandemic, COVID-19 is emerging as a major contributing factor to fueling community fears and exacerbating social isolation in connection with drug abuse. Most concerning is how spatial social isolation, when combined with pandemic social isolation and fear of the police, may operate together in ways that contribute to higher rates of both overdose as well as COVID-19 infection.
Social Isolation as a Way of Life
Life in McKeesport, as explained by the people we interviewed is “difficult.” Reasons given for this vary. Interviews attest to struggles with drugs, money, and life in general. Interesting among our results is how they report a perception of stigma that is at odds with a perverse sense of pride, as they associate their social identities with a city that is somewhat nationally famous due to its ranking as a “high crime” area.
Our research subjects revealed themselves to be individuals whose social isolation is not only personally frustrating, it is compounded by a constantly evolving social context; one that is at once a product of uneven spatial development, even as it is also not overly determined by arbitrary geographic boundaries. Not unlike the landscape that surrounds them, their lives are marked by constant flux and turmoil. This is not surprising, given how research has demonstrated this is customary among groups who live in poverty. Lockdowns make prisons out of homes that are already located in neighborhoods that might be thought of as “open air prisons.”
Uneven regional development, which was occasioned by a combination of different social and economic development policies implemented over the last 40 years, has asserted a profound negative impact on the people who live here and who have come to embody these policy failures. Their life experiences and personal narratives attest to how regional economic tensions that produced community growth in some areas were achieved at the expense of managed decay in others. McKeesport’s structural vulnerabilities related to poverty and failed development, while not necessarily causal, now independently exert a major influence over the life choices and health outcomes of the people subject to them.
The social dynamics that we highlight are not merely abstract or academic; they are observable and significant for reasons that they are fully embodied and currently being lived. Individual and social factors combine here and produce a social order that is disordering. Drug problems, violent crime, and contagion are all predictable results. Consequently, this is why we think it can be argued that public health policies, policing policies, and drug problems in McKeesport are embedded within a political economy of pain and injury; one that not only produces, but normalizes violent policing practices that contribute to the social isolation of people, who are using drugs to cope with the pain of living under these conditions. Given this, it is not sufficient to merely call attention to the individual behavioral aspects of drug problems without also calling attention to the conditions of capitalism that contribute to spatially uneven development and social isolation factors which have become infrastructural drivers of the problem. By placing our preliminary results within this wider social context, it is hoped that government policy planners will take a more comprehensive approach to problem solving, as problems like opioid abuse and overdose cut across multiple and different dimensions of civic engagement.
Fear of Police
Even though our survey, which we conducted in advance of interviews, did not ask specific questions about police encounters, the topic was almost always brought up by people with whom we spoke. Interview subjects revealed a deep-seated fear of police encounters, as they recounted stories to us about calling for medical assistance when they observed friends and partners overdosing. Not surprisingly, subjects who acknowledged arrest records to us were the most fearful of all. They worried that if the police found them to be in possession of a reversal drug like Narcan this might be seen as evidence of personal drug use or worse drug dealing. More than one of our subjects shared that this fear prevented them from calling for help for friends who they witnessed overdosing. They also expressed worry that the police might not respond to calls for overdose due to increased fear of COVID-19; that as drug users, they are already understood to be socially, if not virally, contaminated.
How Does Pandemic-related Social Isolation Impact People Who Use Drugs and Overdose?
While it is too early to say at this point in our work, we continue our work to discover how life under COVID-19 may pose increased risks for people who take opioids in McKeesport. As research has noted, the risk of fatal overdose is increased among individuals who are forced to use alone. Those who have been precipitously cut off from treatment, or whose treatment modalities have shifted as a result of the pandemic, may face particularly high risks in the wake of relapse. Important questions remain, however, about what will happen when poverty and opioid induced social isolation are combined with the added social distancing restrictions imposed by COVID-19.
Our study, which was conducted as the pandemic started to unfold, asked: What are the social factors that influence opioid overdose? We aimed to learn more about how the spatial social dynamics that contribute to drug overdose might also influence and interact with the social dynamics of COVID-19. This work led us to acquire a deeper understanding of how McKeesport area residents respond to the challenges of living in a deteriorated place, such that “social isolation” is practiced proactively as a way of life.
Moving forward, we advise that city planners adopt a harm reduction approach rather than a policing approach to address the problem of opioid abuse and overdose in McKeesport. These results are consistent with previous research that has found criminal justice approaches to managing overdose, which emphasize surveillance and arrest of users, are not as effective as public health approaches. Greater ongoing effort is necessary to help stabilize the lives of vulnerable community members and to help improve the self-efficacy of those who are stigmatized by drug use, for being jobless, disabled, and for simply being poor. More policing cannot be the policy answer to address the failed use of policing to solve the drug problem. Alternatively, a harm reduction strategy could help solve the problem of opioid overdose and further serve to mitigate the isolating experience of living in McKeesport. In what represents an ironic turn of fate, we find the pandemic may represent an opportunity to better understand as well as address the social factors that are bound up in opioid use and overdose.
The site of fieldwork is always a political location. This holds true in our efforts to explore McKeesport as a locality. The pandemic necessarily put pressure on research decisions to “go there” or “stay here” in order to remain safe. COVID-19, in this manner, creates temporal disruptions across multiple registers of living and being, where the “interval” may now be as important as the study frame. Knowledge production, as such, is also suspended. As we remain on standby, we recognize that we are empowered to make the decision to “stay safe,” which is itself a form of privilege. Moving in and out of the field and becoming socially isolated researchers in the process, we thus acknowledge our embodied engagement with our surroundings and reflect on this and how it impacts our research. Our field team of interlocutors unavoidably shares the affective state of social isolation with our research subjects, who we noted have at times reported finding life as isolates to be unbearable. Now, “the field” of social isolation is everywhere. We draw from this newly acquired insight as we continue to evaluate our findings. As the pandemic continues, we will continue to evaluate how attachments as well as disassociations from constructs like space and place will impact public health as well as our social responsibilities to forge connectedness with those who vulnerable and alone.
Portions of this article are part of an accepted author manuscript, Sandra L. Trappen and Katherine J. McLean, Policing Pain: Non-Criminal Justice Approaches to Managing Opioid Overdose During the COVID-19 Pandemic, The Journal of Prevention and Intervention in the Community, Volume 49, Issue 2, (2021). The original version of the article is scheduled for publication by Taylor & Francis can be accessed online in early 2021 at http://www.tandfonline.com