From the beginning, the United States has been founded on principles of social equality and taken pride in its absence of a structured class system. Yet the life experiences of most Americans indicate that one’s financial resources and social standing can make a difference in one’s health, material prosperity, and overall quality of life. Statistics show that socioeconomic status can have a strong impact on one’s risk of abusing drugs and alcohol. By the same token, an individual’s financial standing can help to determine whether the person enters treatment for addiction and the level of care that the person is able to receive.
Cultural Stereotypes about Income and Addiction
There are several pervasive cultural stereotypes about socioeconomic status and addiction in the US. One stereotype holds that drug addiction and alcoholism primarily affect the poor, who use drugs and alcohol as a way to cope with the stress of poverty. Another stereotype states that drug and alcohol abuse are moral failings that create an underclass of impoverished, chronically unemployed individuals who have little hope of ever rising above their miserable circumstances.
There are also negative social stereotypes about substance abuse among the wealthy. The notion of the “idle rich” includes stereotypes about the wealthy as morally weak individuals who are prone to alcohol abuse and drug addiction. Lacking the need to work for a living, they are free to indulge in compulsive behavior and substance abuse without the fear of losing their jobs or social standing.
In reality, addiction crosses the boundaries of wealth and social status, affecting people from all socioeconomic groups. The National Institute on Drug Abuse takes the position that addiction is not a moral failing or a character defect, but a progressive yet treatable brain disease characterized by compulsive substance abuse and repeated relapse. Myths and misconceptions about addiction and socioeconomic status get in the way with developing real solutions for the equal-opportunity problem of substance abuse.
Substance Abuse and Income Level
Income level can affect drug or alcohol use in many ways. It might make sense to assume that individuals in a poor or lower-middle-class neighborhood would be more likely to abuse alcohol and drugs because of financial stress, lack of education about substance abuse, and insufficient resources for treatment. However, statistics indicate that drug and alcohol use actually increase in higher income groups.
According to the Gallup Poll, alcohol use is more common among upper-class, highly educated Americans:
- About 80 percent of upper-income survey respondents reported drinking alcohol, compared with approximately 50 percent of lower-income respondents.
- Approximately 78 percent of individuals with an income of $75,000 or more reported that they drink, compared with 45 percent of individuals with an income of $30,000 or less.
- About 80 percent of college graduates reported that they drink, compared with 52 percent of those who had a high-school education or less.
- Altogether, 64 percent of American adults from all income categories reported that they use alcohol.
Why does alcohol use increase with an individual’s level of income and education? The answer may be that wealthier individuals are able to afford more alcohol, and they are more likely to attend social activities where alcohol is served, such as parties, fundraisers, and sporting events. However, the exact explanation for this disparity remains unclear.
A study published in the American Journal of Preventive Medicine confirms the results of the Gallup Poll. The journal study revealed that individuals living in higher-income neighborhoods had higher rates of alcohol and marijuana use than those who live in lower-income neighborhoods. These results may indicate that wealthier individuals have easier access to alcohol and marijuana, both because of their financial means and their social activities. On the other hand, this study and the Gallup Poll may also contradict the stereotype that low-income individuals have higher levels of stress, which leads to higher rates of drug and alcohol use. It is possible that the factors causing stress among wealthy and middleclass Americans — such as financial concerns, relationship conflicts, or parenting issues — are as influential and harmful as the factors that cause anxiety or depression among the poor.
Heavy Drinking and Income Level
While alcohol use in general may be more common among Americans with higher incomes and higher levels of education, heavy drinking may be more common among the poor. A study published in Social Science & Medicine showed that individuals with a history of belonging to a lower-income socioeconomic group were more likely to engage in heavy drinking or binge drinking (the consumption of five or more drinks in one sitting), while individuals in higher-income groups were more likely to engage in light or social drinking. Individuals from a working-class background were more likely to indulge in heavy drinking; however, they were also more likely to be completely abstinent from alcohol than the white-collar Americans who were studied.
Among American adolescents, however, heavy alcohol use could be more widespread in individuals whose families have higher levels of income and education. The Journal of Studies on Alcohol and Drugsfound that teens whose parents had a higher education and a higher household income were more likely to engage in heavy drinking episodes and to use marijuana than young people from lower-income homes whose parents were less educated. This study contradicts the cultural misconception that privileged teens are protected from the destructive effects of alcohol and drugs, while low-income adolescents are more prone to high-risk behavior and substance abuse.
Homelessness and Substance Abuse
In mainstream American society, homeless Americans represent the lowest rung of the socioeconomic ladder. The financial instability of these individuals makes it difficult to track their use of drugs or alcohol. The Substance Abuse and Mental Health Services Administration estimates that 34.7 percent of homeless adults living in shelters have drug or alcohol use disorders; however, this number does not account for the thousands of homeless people who live unsheltered in the streets.
Mental illness, which often goes hand in hand with substance abuse, is also common, affecting over 26 percent of sheltered homeless adults. In the homeless, psychiatric disorders like depression, schizophrenia, and bipolar disorder can be a greater barrier to treatment than socioeconomic obstacles. Many homeless adults resist getting treatment because of irrational suspicions about others, low levels of motivation, or fears of social judgment or legal persecution. The National Council for the Homeless points out that for most of these individuals, fulfilling basic survival needs, like the need for food or shelter, takes priority over getting help for substance abuse or seeking treatment for mental illness. In addition, many homeless people lack a support system of family and friends who will motivate or encourage them to get help.
Opioid Addiction and Socioeconomic Status
Although the results of the Gallup Poll indicate that alcohol use is higher among the wealthy, the abuse of illegal and prescription opioids may be highest among the poor. Prescription opioid addiction has reached epidemic proportions in the US. Statistics from the Centers for Disease Control and Prevention (CDC) state that as of 2011, the rate of overdose deaths from opioid prescription drugs, including popular pain relievers containing oxycodone (OxyContin, Percocet), hydrocodone (Vicodin, Norco), and hydromorphone (Dilaudid) were highest in states with higher poverty levels.
Possible explanations for the higher prevalence of opioid abuse and overdose among the poor include:
- Inadequate follow-up care for low-income patients being treated for chronic pain at publicly funded medical clinics
- Self-medication for the stress and depression associated with poverty
- Limited access to opioid treatment programs and rehab facilities
- Lack of education about the dangers of prescription medication abuse
Although there are links between poverty and opioid abuse, addiction to prescription opioids and illicit drugs like heroin affects people in all income levels. In fact, the CDC reports that the greatest increase in heroin use since 2002 has occurred among demographic groups that have had traditionally low levels of use, including women, Americans with higher incomes, and people who have health insurance coverage.
A comparison of figures from 2002 to 2013 from the CDC shows that heroin use increased the most in Americans with an average household income of $20,000-$49,000 (an increase of 77 percent), while the increase in use in Americans with an income over $50,000 and in those with an income of $20,000 or less was very similar (60 percent versus 62 percent). These statistics show that more preventive services are needed for all socioeconomic groups, as well as greater access to substance abuse treatment facilities across the board.
Is Socioeconomic Status a Barrier to Treatment?
The lack of health insurance and/or financial resources is cited as a barrier to treatment in national surveys. According to the National Survey on Drug Use and Health, 37.3 percent of Americans age 12 and older who did not receive treatment for addiction said they did not seek help because they did not have health insurance or could not afford rehab. The lack of financial resources/insurance was the most commonly reported reason for not receiving treatment; the second most widely reported reason was that the individual was not ready to stop using (24.5 percent).
A study published in the Journal of Substance Abuse Treatment suggests that while drug and alcohol users believe that a lack of financial resources is an obstacle to rehab, it is not necessarily the most important obstacle. In this study, over 300 patients were surveyed at a centralized intake unit to find out what they considered to be the most significant barriers to treatment. Many of the patients who identified themselves as alcoholic stated that the most important reason for avoiding treatment was that they believed they could help themselves rather than seeking help from others. Other barriers cited as more significant than a lack of financial resources were concerns about privacy and the belief that treatment was not necessary. Additional obstacles named by the survey participants were the lack of childcare or convenient transportation.
Statistics on substance abuse in the U.S. indicate that there is clearly a need for more affordable treatment services for all Americans, regardless of their income level. The Affordable Care Act, which includes substance abuse treatment as an essential health benefit, will make rehab more accessible to Americans with low income levels. As of 2014, public assistance programs like Medicaid have historically provided little assistance for drug or alcohol rehab. However, these programs will now receive more reimbursement for substance abuse treatment, which will make it easier for the poor to benefit from recovery services.
How Americans Pay for Treatment
No matter what their income or social position may be, the majority of Americans who need substance abuse treatment wonder how they will pay for rehab. The National Survey of Substance Abuse Treatment Services (NSSATS) for 2012 listed the following forms of payment, along with the percentage of treatment facilities that accepted those payment options:
- Self-payment (cash or other sources): 90 percent
- Private health insurance: 65 percent
- Medicaid: 58 percent
- State-financed health insurance: 40 percent
- Medicare: 33 percent
- Federal military insurance: 33 percent
In general, privately funded treatment centers were less likely to accept payment through federal or state assistance programs, like Medicare, while federally funded programs were less likely to accept cash payment. Out of the facilities surveyed, 62 percent reported that they had a sliding scale option, which allows clients to pay for treatment based on their financial resources.
According to the 2013 National Survey on Drug Use and Health, the majority of Americans who received substance abuse treatment at a specialty facility paid with private health insurance (41.7 percent), while 40.6 percent used their own income or savings, 29 percent used Medicaid, and 23 percent used money contributed by family members. No matter what an individual’s socioeconomic status may be, there are treatment options available for anyone who is committed to getting help for drug or alcohol addiction.
- AlcoholicsAnonymous.org Since the beginning of Alcoholics Anonymous (AA) in 1935, this program has served as an example of a free self-help support group that transcends all socioeconomic, racial, religious, and geographic boundaries. This website offers a wealth of resources to individuals seeking freedom from substance abuse, including an introduction to the 12 Steps, a history of AA, access to AA literature, and an AA group locator.
- National Coalition for the Homeless: Substance Abuse and Homelessness: This website, sponsored by one of the country’s largest advocacy groups for homeless Americans, provides detailed information, fact sheets, and news about the complex relationship between homelessness and drug or alcohol addiction.
- Office of National Drug Control Policy: Substance Abuse and the Affordable Care Act: This government website explains the relationship between recent healthcare reform laws and substance abuse treatment, as outlined in the Affordable Care Act.
- State & Local Government on the Net: State Substance Abuse Sites: This website provides links to the public agencies that oversee substance abuse treatment in each state. Most states offer public health programs to prevent and treat drug and alcohol abuse, which can be accessed through the websites listed in this portal.
- Substance Abuse and Mental Health Services Administration (SAMHSA): National Helpline:This government agency provides 24-hour assistance by telephone for individuals in need of substance abuse treatment or mental healthcare. Referrals, information, and support are provided at 1-800-662-HELP (4357).