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Markkula Center for Applied Ethics

Shades of Bias: Ethical Challenges at the Crossroad of Poverty, Addiction and Healthcare Outcomes

A person wearing a hoodie is sitting outdoors against a graffiti filled concrete wall and is holding their head with fisted hands. One hand holds a hypodermic needle.

A person wearing a hoodie is sitting outdoors against a graffiti filled concrete wall and is holding their head with fisted hands. One hand holds a hypodermic needle.

Tisha Hartman ’24

Лечение Наркомании/ Pixabay

Tisha Hartman is majoring in neuroscience with a minor in biology and is a 2022-23 health care ethics intern at the Markkula Center for Applied Ethics. Views are her own.


Poverty, Race, and Addiction

More than 40 million people live in poverty in the U.S., representing 12% of our national population. It’s well documented that poverty is strongly correlated with addiction. A study conducted in 2019 found that heroin and cocaine use was most concentrated “in neighborhoods with the highest rates of poverty.” Another study cited both poverty and racism as structural factors contributing to addiction, and suggested “opioid use is associated with economic hardship and absence from the labor market.” Furthering this, both poverty and race have been found to significantly correspond with opioid-related overdose death rates. Additionally, the rate of overdose mortality in Black men is now rising faster than any other racial or ethnic demographic. Overwhelmingly we see income, education, race, and neighborhood poverty levels exerting influence on the rates of addiction and overdose.

Sadly, drug overdose is now the leading cause of injury-related death in the United States and nearly 70% of these deaths involve opioids. Addiction is an often misunderstood medical disorder characterized by profound alterations in the brain's reward, motivation, and memory circuitry, and is triggered through repeated exposure to a substance with the net effect of impairing brain function in the long-term. 

Substance Use Disorder (SUD) is how the DSM-5 classifies addiction for clinical diagnosis, and it is estimated that over 21 million people have a diagnosable SUD in the U.S., while only 3.8 million are receiving treatment for it each year. Those estimates leave a staggering 82% of those battling addiction in the U.S. without care, and those numbers are shaking out to be more than just estimates. In fact, one study found that 70% of patients with diagnosed opioid use disorder were not receiving treatment for it.

Truly untreated SUD is a public health crisis, and it is claiming lives every day. In January, Dr. Rahul Gupta, director of the White House Office of National Drug Control Policy released a statement estimating that 107,477 people died from overdose last year alone (2022 estimate). If Dr. Gupta’s estimate is accurate, that means 294 people are dying in the U.S. from an overdose every single day and we are seeing this figure increase year over year.

Stymied by Stigma

What’s interesting about this is that research is showing that there has been a shift away from overdoses resulting from prescribed opioid and heroin use, as was prevalent in the early 2000’s to overdoses from illicit street use. While 24% of all opioid deaths were from prescription opioids in 2020, this is down from 78% in 2007. Yet in striking contrast to the decline in prescription-related overdose deaths, CDC overdose data shows that overdose deaths in total have nearly doubled in the same amount of time.

This means fewer people are seeking treatment, while more people are using and ultimately dying. So what could be driving a shift away from medically overseen treatment, to more dangerous street use? The answer to this is complex and multifaceted, and while there are certainly a multitude of systemic and practical barriers, health care provider attitudes and biases towards addiction present ethical challenges that require closer examination.

One study cited that lack of treatment also stems from the false belief that the use of agonists or partial agonists merely substitutes one addiction for another. Another study found that physician willingness to treat addiction was lower when the physicians believed addiction was a choice within the addict’s control, or if the physician believed they themselves could not experience addiction. Researchers also found that health care providers held biases around the belief that people with SUD monopolized health care resources based on a higher number of emergency department visits.

But these aren’t the only biases people with SUD face in seeking help. People with SUD are often judged, mistreated, and left untreated by their health care providers, who regard addiction as a moral weakness instead of a chronic medical illness. One study found that more than 78% of people with SUD had reported at least one instance of bias when engaging with the health care system. This study also found that people with SUD reported that health care providers treated them differently after they found out about their addiction, and that because of these experiences people with SUD felt “victimized, judged, and ignored” by their health care providers. 

Another study found that people with SUD are delaying their health care visits to avoid the stigma, and that this is resulting in advancing disease and higher medical costs overall. These findings are powerful indicators of how social stigma is seeping into health care and negatively influencing health outcomes and mortality for a population already disadvantaged by society. People with SUD are typically living in extreme poverty, facing poor nutrition, poor mental health, poor immunity, and high rates of infectious disease, yet the research is showing that people with SUD face even more social stigma when trying to seek help. Health care provider stigma represents a significant barrier to treatment and recovery across all facets of health care.

Providers Most Vulnerable to Biases

Since most people inherently have some level of implicit and explicit biases, no health care specialty is immune, but there are some areas of health care where these biases have shown statistically significant prevalence. Specifically in the departments of emergency medicine and obstetrics/gynecology, which were both shown to have the highest explicit bias scores regarding whether people with SUD deserved access to quality health care. The study further stated that the majority of labor and delivery nurses believed pregnant women with SUD should be imprisoned or sent to rehabilitation centers, and that the more experience a nurse had in working with people with SUD the higher their scores were in negative biases.

From the outside looking in, it might be difficult to understand how factors like poverty, trauma, education, and lack of support can coalesce into addiction and how that addiction fuels compulsion that is so strong it overrides biologically embedded survival instincts and even the instinct to protect one's own offspring. But the stakes are big when the death tolls are high and unborn children are paying the price, and as we’ve already established SUD is on the rise and it’s affecting more pregnant women than ever before. In fact, a 2016 Kaiser study found that pregnant women accounted for the largest share of enrollees receiving opioid prescriptions, and a 2017 survey conducted by SAMHSA indicated that the majority of new heroin users were white women. Another study stated that substance use during pregnancy was not rare and continues to increase.

In fact, the correlates of poverty and addiction were found to be particularly evident for women showing that they came from “the most disadvantaged” communities. Another study discussed how women with SUD seek treatment at even lower rates than men due to being judged more harshly by society and their health care providers. The evidence has long suggested that services to people with SUD improve outcomes and have been shown to not increase drug use. But society and particularly health care as an institution must take new steps to remove barriers in accessing treatment, specifically by addressing provider biases.

Our most vulnerable populations need our help. These are populations of extreme poverty, intersecting with race, sex, and addiction and the stakes are high morbidity for both adults and unborn children. Hospitals and medical ethics boards need to have provider biases on their radar and be testing for it at onboarding and throughout employment, while also providing ongoing training on the intersections of addiction, biases and health outcomes to increase compassion and remove these barriers to treatment.


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Jun 12, 2023

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