The phenomenological, social network, social norms, and economic context of substance use and HIV prevention and treatment: A poverty of meanings

There is dearth of creative interventions and conceptualizations in the fields of substance use prevention and treatment and in the fields of HIV prevention and care. Many of our evidence-based interventions are designed by the affluent, telling poor people how to live their lives, especially what they shouldn’t do. These interventions are clearly designed with the best of intentions. Yet there are several areas of concern about their nature, focus, and outcomes. In our striving for documenting universal truths, investigators have paid insufficient attention to the phenomenological, social, physical, and human context and consequence of drug use.

A common public health perspective on drug use is trying to balance the individuals’ rights with the safety and well-being of society (Etzioni, 2002). This perspective tends to treat people as rational decision makers and societies as homogeneous. The first concern about this approach of focusing of individual versus societal rights is the models of human nature and cognition used in many of these analyses. Often investigators posit high rational, information processing perspective on human decision making (Green and Shapiro, 1994). They make assumptions about human nature based on idealized Western, individualistic ideologies (Wrightsman,1992).

Decisions about drug use initiation, maintenance, and cessation are not solely rational processes. But how do we best model the physiological and psychosocial aspects of decision making and how substance use is intertwined with these processes? In addition to models that invoke neural pathways, rewards, and punishments, another important element is sense making and meaning. Few substance use and HIV prevention interventions address how people make sense of the world and ascribe meanings (Harling, 2007; Unger, 2014). The drug treatment adage of avoiding people and places reduces triggers and negative social influences to use drugs, but what if the “people” are family and partners and the “places” are home and neighborhood? What relationship is more meaningful, a drug treatment counselor or a family member? One reason that NA/AA has been a sustainable and low cost intervention is that it provides meaningful social roles and avenues to inhabit these roles. Galanter’s (1997) comparison between new religious groups (or cults) and NA/AA highlights how social process and meaning systems are critical to both types of social organizations. In developing substance use and HIV prevention and interventions, we need to ask what valued social roles and meaningful activities are we providing. “Just say no” is truly the antithesis of meaningfulness.

In addition to the social organization of self-help groups, the social organization of social networks and communities provide meaning, belongingness, and coherence. While networks and communities have messy and opaque boundaries, they are the social fabric that promote and maintain social norms regarding substance use and HIV risk behaviors (Nguyen et al., 2012). But how do assist individuals and communities in organizing their social environments to foster health behaviors? In the field of alcohol control investigators have tried to alter social norms on college campuses with mixed success (Lewis, & Neighbors, 2006). One weakness with this approach is that often the focus is on individual level social norms. Norms differ by context, networks, and organizations. There have been few attempts to change and sustain alcohol norms on subgroup or network levels and truly involve subgroups in altering the social norms. Without understanding the diversity and context of alcohol norms on college campuses it is unlikely that massive campaigns to alter alcohol use norms will be successful.

In the field of tobacco control the social norms regarding smoking have dramatically changed. Cigarette smoking is now less acceptable and more stigmatized (Hamilton, Biener, & Brennan, 2008). Lower income neighborhoods continue to have higher rates of smoking, but now this behavior is more stigmatized and a larger proportion of the income of impoverished residents is spent on tobacco products. Certainly, legislation on control tobacco use has been a great public health success, saving millions of lives, but it is critical to examine the social context of such interventions, address the unintended negative consequences (especially for impoverished communities), and appropriately tailor tobacco control policies. Interventions that increase social network support and community empowerment and those that reduce stress and provide meaningful activities in impoverished neighborhoods may be one avenue to improve health related to substance use and hence decrease tobacco use. There are other common approaches to tobacco control such as reduce access and advertising, but it may behoove us to address factors that enhance the social and physical context rather than only focusing on making the acquisition of tobacco products more difficult.

Although many public health researcher programs emphasize the dangers and evils of substance use, they are often developed by people who have many alternatives and options in their lives. Substance use disproportionally impacts impoverished communities. It may be beneficial for investigators to ask the question of why “shouldn’t people use drugs?” What are the alternatives? Without jobs, why worry about drug use causing the loss of a job? Without the prospect of a good future, why not live in the moment? Addictive substances can lead to a cascade of hellish events for the users and their family and friends. These events may future reduce economic opportunities and drain existing meager resources. A history of substance use may also lead to employment discrimination (Baldwin, Marcus, & De Simone, 2010). This is not to say that more affluent communities and individuals do not suffer from the deleterious physiological, psychological, social, and economic impact of drug dependence; however, given the disproportionate impact of substance abuse on impoverished populations, disproportionate resources need to be spent in poorer communities to address and prevent substance use.

Enhancing communities’ economic well-being is undoubtedly a key approach to improve health outcomes associated with substance use; however, it behooves us to look at economic factors that promote drug use. These are the formal and informal economies. With strong profit motives, purveyors of licit and illicit substances are likely to find ingenious methods to distribute their products. They also have far more resources than health researcher and practitioners to develop effective interventions that promote increased substance use. Consequently, it is imperative to document and disseminate information on the wide range of harms, as well as benefits, caused by specific drugs to enlist public and political support for research and policies to address substance use.

Economics is one form of power that drives drug use. Individuals, such as drug treatment experts, with power and privilege help determine the social meanings of drug use and treatments. Investigators are in a position to ascribe a wide range of meanings to drug use and drug users. The meanings ascribed to drug use are often narrow. In our research based harm reduction interventions for HIV prevention in Baltimore, Maryland, we often find that participants will initially report that their primary goal of joining the study is to stop using opiates and cocaine. They are often surprised when the group facilitator acknowledges this is valid goal but then goes on to say that it is not the only worthy goal, and that active users have a range of viable options to improve their health and help their family and friends. For some drug users the meaning of becoming clean of drugs becomes entangled with cleaning up one’s life. This is not to say that cessation isn’t a lofty goal, but in impoverished neighborhoods this outcome may not lead to employment or other valued activities and goals. Our interventions need to address a range of outcomes so that participants can achieve meaningful successes and address some of the numerous obstacles that impede their social and psychological well-being.

As the purveyors of meanings, researchers and practitioners, as well as political actors, use the meanings of drug use as a form of social control, and only a limited number of treatment and prevention approaches are deemed valid and acceptable. Often in treatment programs there is an expectation for repentance for drug use. Drug treatment programs usually focus on controlling and eradicating undesirable behaviors and continued drug use may leads to ejecting from the program. Those in the role of drug experts are prone to claim authority on defining the meanings of drug use and treatment. Those who do not agree with these prescribed meanings may be accused of being soft on drugs or naïve.

Clearly, our approaches to substance use prevention and treatment and HIV prevention and care need to be more innovative, holistic, and based in the context of neighborhoods, networks, and communities. Scientific and practices paradigms are invaluable for addressing substance abuse but they can also serve as blinders due to an overreliance on the prevailing paradigms of how to do good research and practice. In developing new perspectives, we need to be able to traverse level of analyses from individual meanings to corporate monopolies to have a powerful and sustained impact on the people’s physical and mental well-being associated with substance use.