Social Infrastructure and Recent Surges in Opioid-Related Deaths Amid the Pandemic

September 8, 2020

By Karen Otzen, senior strategic project manager, Poverty Solutions at U-M

According to the American Medical Association, more than 35 U.S. states have reported an increase in opioid-related deaths since the start of the COVID-19 pandemic. Some addiction experts argue that social isolation resulting from the social distancing guidelines required to slow the spread of the virus may be helping to fuel the surge in opioid overdoses. Our socially distant “new normal” is preventing many struggling with substance abuse disorder from receiving in-person counseling, harm reduction services, and other social supports. Social isolation, more generally, stands contrary to most addiction recovery efforts. The National Institute of Environmental Health and Sciences explains that social isolation makes it more difficult for people to maintain their mental health, particularly for those in recovery from addiction, because it can trigger feelings of loneliness, stress, depression, and anxiety — all factors that increase risk of drug use.

With the shutdown of workplaces, local eateries and bars, sports and recreation facilities, and schools, we’ve lost more than a sense of normalcy, but access to the very places that previously supported our ability to interact and connect with others. Sociologist Eric Klinenberg highlights the importance of such places, calling them “social infrastructure.” He says social infrastructure describes “the physical places and organizations that shape the way people interact.” It is “not ‘social capital’ — a concept commonly used to measure people’s relationships and interpersonal networks — but the physical conditions that determine whether social capital develops.” It is defined by its ability to support connection, yet many of these spaces and places have the added benefit of promoting leisure and play. In fact, social connectivity, and the structures that support it, have been found to be important for human health, longevity, and even community resiliency. 

One day, the pandemic will pass and places like bars, beauty shops, and bowling alleys will open, where we can gather with friends and neighbors and rebuild the social connection essential to our health and happiness. But what about communities where social infrastructure was already lacking or on the decline pre-pandemic? Through a study titled, “Understanding Communities of Deep Disadvantage,” University of Michigan and Princeton University researchers find preliminary evidence that in America’s most disadvantaged communities, lifting stay-at-home orders will do little to relieve social isolation and curb the rising rates of opioid-related deaths. 

Understanding Communities of Deep Disadvantage: The Study

To understand disadvantage across the U.S., University of Michigan and Princeton researchers developed an Index of Deep Disadvantage that takes a holistic look at disadvantage, using health indicators (life expectancy, low infant birth weight), poverty metrics (rates of poverty and deep poverty), and social mobility data (Opportunity Insights Mobility Metrics).

Learn more about the Understanding Communities of Deep Disadvantage study 

From their analysis, researchers find that America’s most disadvantaged communities are more commonly rural than many might expect and that they have a long history of racial and environmental exploitation. They also find that people living in the most disadvantaged areas are more likely to die a full 10 years before their counterparts in the most advantaged areas, and people in the most disadvantaged areas are four times more likely to live in poverty. Regions with high levels of disadvantage include: the Mississippi Delta, the Cotton Belt, Appalachia, Tribal Nation Lands, areas near the Texas-Mexico border and the Rust Belt cities of Cleveland; Detroit; Flint, Michigan; and Gary, Indiana. 

To gain a deeper understanding of America’s most disadvantaged communities, researchers embedded in a handful of these places for  10-12 weeks. There they interviewed community leaders and people living in poverty to gain a better understanding of dynamics at the individual and community level that are creating or maintaining barriers to opportunity.

 In Clay County, Kentucky, interviewees told researchers the severity and widespread nature of drug use in their community is partly due to the fact “there is nothing to do but drugs.” 

“There wasn’t nothing to do. There ain’t nothing around here to do. … That’s the big flaw around here. That’s why I think everybody turns to drugs around here,” said Travis, a Clay County resident.

Researchers heard the same thing over and over: “There’s nothing to do.” The roller rink closed down, the movie theater was repurposed as Pentecostal church, and  many of the stores closed. Even the public park was paved over for construction of a new road. Travis wasn’t the only interviewee to link these changes to the drug crisis, the message was widespread.

Traditional Forms of Social Infrastructure are on the Decline

The decline in “things to do” that Clay County residents report parallels national trends in the numbers of business establishments traditionally used for casual, frequent, and low-barrier interaction and leisure. For instance, according to the U.S. Census County Business Patterns data, between 1986 and 2016, the number of bowling alleys in the United States fell 40% and the number of movie theaters fell by 34%.

The decline of movie theaters, bowling alleys, and local bars follows a similar pattern in rural and urban communities in the United States. However, in rural communities, beauty and barber shops ― two forms of social infrastructure that have been particularly important to the social fabric in predominantly Black communities ― have seen a respective decline of 30% and 36% that the rest of the country has not. While some people equate rurality with whiteness, U-M and Princeton researchers find that is not the case. In fact, Many of America’s places of deepest disadvantage, many of which are rural, are in fact racially and ethnically diverse or are disproportionately made up of underrepresented people of color. 

Source: United States Census, County Business Patterns 1986-2016

 

Source: United States Census, County Business Patterns 1986-2016

Looking at numerous examples of the changing prevalence of different types of establishments that could be classified as social infrastructure, we start to see a trend. The traditional places and spaces known for providing easy and inexpensive access to social interaction like bowling alleys, movie theaters, and local bars are declining everywhere. In rural America, the decline in traditional forms of social infrastructure extends even further.

The number of other types of establishments where social gathering can and does occur is increasing. Fortunately, we see a rise in the number of libraries in both rural and urban areas, a core example of social infrastructure. We also see a rise in the number of eating places and retail bakeries across the U.S. Evidence from the USDA suggests fast food establishments are largely driving the increased food service/bakery options across the U.S., and particularly in rural areas. Fast food restaurants, as journalist Adam Chandler writes in his piece for the Atlantic, may be becoming an increasingly important setting for social interaction among many people. However, U-M and Princeton’s research suggests that in many rural communities, growth in fast food restaurants has tended to be strategically placed along major highways and is patronized mainly by those passing through for a quick bite. 

New types of social infrastructure — ones that are more privatized, more expensive, and less accessible  — also seem to be emerging. For example we see a rise in the number of public golf courses and membership sports and recreation clubs, which include county clubs, golf, tennis, and other amature sports clubs restricted for use by members and their guests.  

The literature supports this trend. Sociologist Ray Oldenburg documents a trend toward private, individualized leisure and urban planning that has decreased walkability and limited commercial establishments in residential areas. Logan and Molotch (1987) point to the push to view public spaces more for their potential economic value, rather than their contribution to quality of life. Crane (2000) notes that the privatization and policing of community spaces has been used as a means to exclude those that community members may perceive as “threatening,” or “annoying” such as young adults “hanging out.” And Mair (2009) posits that rural communities are particularly underserved by sites for shared leisure, due to declining and aging population, geographic isolation, and financial restructuring.

Bowling alleys, once a staple structure supporting American social life, represent an example of social infrastructure that has become less accessible over time. In his book, “Bowling Alone,” Robert Putnam points to declining trends in league bowling and the rise in “solo bowling”  as a cause and consequence of declining social capital in America. Between 1979 and 2015, membership in American league bowling dropped 83%, and with the number of frequent bowlers declining, many bowling alleys were forced to close and make way for more profitable businesses. 

Other alleys have had to adjust their marketing strategies to match the changing demographics among bowlers. Justin Fox, writes in his op-ed for Bloomberg’s Quint that what was once a blue-collar sport to be played by workers after their shifts, has become a “white-collar” sport played by kids at birthday parties and by adults for a night out with friends. Attempting to cater to changing market demands, many of the bowling alleys that remain have taken on a new, “higher-end” brand image. More and more bowling alleys are upgrading their interiors, offerings, and equipment. Some have added things like rooftop arcades, nightclubs, bistros, and bocce ball. With these changes, bowling tends to cater to higher-income households and tends to be less accessible, particularly in America’s least advantaged communities. In fact, in 2007, 42% of bowlers had household incomes of $75,000 or more and 25% had household incomes of $100,000 or more. The median household income at that time was approximately $50,000 (ACS 1 Year Estimate, 2007, U.S. Census).

Public Spaces, Social Capital, and Drug Use

Clay County residents’ observation that a lack of “things to do” can lead to increased drug use, increased risk of death from overdose, and a decrease in the likelihood of recovery from addiction is well supported by academics, residents of other communities, and journalists alike.

While we cannot point to a single cause of drug use, there is increasing evidence that social cohesion has an important role to play. Anne Case and Angus Deaton, in their 2015 study, find that fatalities from substance abuse and suicide can be linked to large-scale economic and social changes such as job loss and the loss of traditional rituals and social institutions and the support they provide. In Palaces for the People, Eric Klinenberg reports that “there’s a growing body of neurological research showing that opioids are, chemically speaking, a good analog for social connection.” And in 2017, Zoorob and Selemi found large-sample evidence that social capital protects communities against drug overdose. Thus, there is evidence that taking opioids and other drugs can sooth not only physical pain but psychological anguish and feelings of social disconnection.

It hasn’t been only Clay County residents who perceive a relationship between boredom and/or lack of community and dependence on drugs. Sociologist Katherine McLean interviewed 18 clients of a drug treatment facility in McKeesport, Pennsylvania, about their experience with accidental overdose. One interviewee told her, “There’s no sense of community here … not one iota of community here. So, left to your own devices, somebody that’s drinking and drugging is gonna continue drinking and drugging. Nothing else, cause there ain’t shit else to do.”

Willging, Quintero, and Lilliot heard from numerous rural youth in New Mexico about their use of drugs within a sociocultural context widely characterized by having “nothing to do.”

Within the field of journalism, writer Johann Hari gave a popular TED Talk in which he concludes that the opposite of addiction is connection (rather than sobriety). He explains that addiction is less about the pleasure one gains from the substance itself and more closely tied to one’s inability to connect in healthy ways with other human beings. Supporting Hari’s conclusions, Mayo Clinic lists painful feelings such as anxiety, depression, and loneliness as risk factors for drug addiction.

Moving Forward

Both our lived experiences and empirical research underscore the important role social infrastructure plays in preventing drug use and promoting public health more generally within our communities.

The opioid epidemic has long been an issue at a national scale. Medical practitioners overprescribing opioids is a major contributor of addiction. After hitting their peak in 2012, opioid prescription rates, overall, have declined, thanks in large part to concerted efforts to curb the issue by the American Medical Association and the Center for Disease Control. However, in some areas, prescription rates never actually fell. In fact, “in 11% of American counties, often in rural communities clustered in the South, enough opioid prescriptions are being written each year for every man, woman, and child to have one.” (Mann, 2020

Increased social isolation resulting from the 2020 stay-at home and social distancing orders is complicating efforts to prevent drug use, addiction, and overdose everywhere. Yet it is likely having a disproportionately large impact in rural places where the community is already plagued by higher than average rates of opioid prescription and is experiencing a fragile and declining social fabric. When the pandemic passes and we are able to connect with each other again in person, many of America’s most disadvantaged communities will remain isolated and at heightened risk of drug abuse and even overdose. 

Recognizing how important it is that we have places and spaces to interact with others, it’s time we act more intentionally about ensuring the existence of the infrastructure needed to support a strong social fabric within each and every one of our communities.