INCORPORATING THE 

SOCIAL DETERMINANTS OF 

HEALTH INTO SUBSTANCE 

USE PREVENTION 

1 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

TABLE OF CONTENTS 

INTRODUCTION------------------------------------------------------------------------------------------------------2

WHAT ARE THE SOCIAL DETERMINANTS OF HEALTH? ------------------------------------------------------3

ECONOMIC STABILITY ----------------------------------------------------------------------------------------------6

NEIGHBORHOOD AND BUILT ENVIRONMENT -------------------------------------------------------------- 10

SOCIAL AND COMMUNITY CONTEXT ------------------------------------------------------------------------- 12

EDUCATION ACCESS AND QUALITY --------------------------------------------------------------------------- 18

HEALTH CARE ACCESS AND QUALITY ------------------------------------------------------------------------- 21

METHODOLOGY --------------------------------------------------------------------------------------------------- 26

REFERENCES -------------------------------------------------------------------------------------------------------- 28

CONCLUSION------------------------------------------------------------------------------------------------------- 35
2 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

INTRODUCTION

Evidence-based substance misuse prevention starts with a clear understanding of the risk and 

protective factors driving substance misuse and related behavioral health problems present in 

communities. Many factors affect people's risk of misusing substances. Among these, the social 

determinants of health (SDOH) are some of the most important.

This tool is designed to educate prevention professionals about the SDOH, including what SDOH 

are and how they impact the risk of substance use.

The content is organized according the five core domains of the SDOH. For each domain, we 

present a brief description, followed by an exploration of the specific SDOH associated with 

substance misuse-related outcomes, including risk of misuse, misuse rates, substance use 

disorder (SUD) rates, risk of overdose, and many others.

This tool includes the following sections:

• What Are the Social Determinants of Health? Economic Stability 

• Neighborhood and Built Environment 

• Social and Community Context 

• Education Access and Quality 

• Health Care Access and Quality 

• Methodology
3 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

WHAT ARE THE SOCIAL DETERMINANTS OF HEALTH?

SDOH are “big picture” factors that can impact risk of substance misuse—and the likelihood of 

many other health outcomes—across entire communities. The U.S. Department of Health and 

Human Services (HHS) defines SDOH as:

“The conditions in the environments where people are born, live, learn, work, play, 

worship, and age that affect a wide range of health, functioning, and quality-of-life 

outcomes and risks.”

In other words, they are the environmental aspects around us that are potentially influencing 

all aspects of our day-to-day lives and health.

There are myriad ways to think about and organize SDOH. HHS uses a system of five core 

domains: economic stability, education access and quality, health care access and quality, 

neighborhood and built environment, and social and community context. Within each domain 

are many different yet related SDOH. For instance, a few of the many SDOH within health care 

access and quality are rates of insurance coverage, the percent of health care providers who 

offer tele-health services, and access to prenatal care for pregnant women. 
4 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

Social and Community Context

This domain considers people's interpersonal connections, including with family members, 

friends, co-workers, and other community members. It emphasizes the health-related benefits 

of social support within relationships as well as engagement opportunities and social cohesion 

within the broader community. It also emphasizes the health-related challenges of violence 

within relationships and stigma and discrimination within relationships and the broader 

community.

Education Access and Quality

This domain considers access to opportunities that support learning and development during 

early childhood, K- 12 education, vocational training, and higher and continuing education. It 

also considers the quality of all available educational opportunities, including how well they 

support academic and other educational goals as well as the physical, social, and emotional 

well-being of those involved.

Health Care Access and Quality

This domain considers multiple aspects of health care access, including affordability, how easy 

it is for people to physically reach a provider or service, whether a provider or service has 

available resources (e.g., personnel, technology) and can adapt (e.g., appointment times, 

communication strategies) to meet people's needs and preferences, and how comfortable 

people feel with the provider or service. It also considers such elements of health care quality 

as the degree to which it is safe, effective, and person-centered.

Economic Stability

This domain considers the balance between the financial resources available to people and 

what they must spend to live healthy and well. Financial resources include income, benefits, 

savings, home ownership and equity, and other elements of wealth. Such resources influence 

the degree to which people can access health-promoting resources and services. People who 

struggle with economic stability also face many life stressors that can further influence their 

health and well-being.

Neighborhood and Built Environment

This domain focuses on the connections between where people live and their health and wellbeing. It considers characteristics of the many different physical and natural environments in 

which people spend time—for example, lead, mold, or other hazardous conditions in homes, 

schools, and workplaces; access to healthy and culturally-relevant foods, parks, and 
5 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

transportation; air and water quality; and neighborhood and community safety.

The following sections explore each of these domains and their relationship to substance 

misuse in greater detail.
6 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

ECONOMIC STABILITY

About the Domain

Economic Stability considers the balance between the financial resources available to people 

and what they must spend to live healthy and well. Financial resources include income, 

benefits, savings, home ownership and equity, and other elements of wealth. Such resources 

influence the degree to which people can access health-promoting resources and services. 

People who struggle with economic stability also face many life stressors that can further 

influence their health and well-being.

Related Determinants

Within this domain, the SDOH associated with substance misuse-related outcomes include:

1. Employment Status

2. Household Income

3. Housing Status

4. Job Skills Training

Employment Status

Increasing rates of employment is vital to ensuring economic stability for people. Employment 

and underemployment are associated with reduced risk of physical and mental health 

conditions, including experiencing stress-related illnesses. Underemployment is the state of 

having a job with insufficient work (e.g., having a part-time job but wanting a full-time job).

People who are unemployed or underemployed are at greater risk of experiencing heart 

disease, strokes, arthritis, depression, and other issues. They are also less likely to receive 

preventative health services of all kinds. There are numerous programs to increase 

employment rates and improve job quality, including job skills training programs, workplace 

safety regulations, and employee benefit requirements.

Findings from 22 studies show that employment is associated with reduced likelihood of 

substance misuse, greater likelihood of accessing and completing treatment programs if 

substance misuse occurs, and reduced likelihood of experiencing recovery-related 

discrimination or relapse.
7 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

Employment is also associated with reduced risk of overdose, greater access to the opioid 

overdose reversal medication, naloxone, and reduced likelihood of HIV infection. One study 

also found that workplaces with less racial discrimination are associated with reduced rates of 

substance misuse.

However, findings were not uniformly positive.

Some studies found employment associated with greater risk of contracting a sexually 

transmitted infection related to substance misuse, greater use of novel psychoactive 

substances, and greater risk of smokeless tobacco use. Another study found that employment 

while attending college is associated with greater risk of substance use and other negative 

physical and mental health outcomes.

Overall, employment appears to be associated with positive substance misuse-related 

outcomes, as well as improved healthcare outcomes overall. Continued efforts to increase 

employment rates may bring further positive results.

Household Income

Improving the household income of people with insufficient financial resources is vital to 

ensuring their economic stability. In 2023, the federal poverty level was set at an annual income 

below $14,548 for a household of one or below $30,000 for a family of four. More than 37.9 

million people— 11.6% of the U.S. population—lived below the federal poverty level in 2021. 

Living in or near poverty is associated with a wide range of negative health outcomes.

People living in or near poverty face reduced access to a wide range of positive health supports, 

such as education or employment opportunities. They also face an increased likelihood of 

experiencing negative health risk factors, such as unstable housing and institutional 

discrimination. As a result, poverty and low household income are associated with increased 

risk of morbidity and mortality from numerous health conditions. Poor health is also associated 

with reduced income, creating a “health-poverty trap.”

Findings from 21 studies show that lower household income is associated with increased risk of 

substance misuse, higher rates of fatal overdoses, and increased likelihood of experiencing 

other consequences—such as contracting HIV from injection drug use. Lower household 

income is also associated with reduced likelihood of being screened for substance misuse, 

receiving treatment services for substance misuse or HIV, or remaining in remission after 

receiving treatment. However, findings around alcohol misuse were mixed. One study found 
8 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

lower household income associated with greater risk of binge drinking among men and a lower 

risk among women. Another study found that households that lost income during the Great 

Recession (2007 to 2009) decreased their overall alcohol consumption—though they also saw 

an increase in depression. Lastly, one study found that access to prevention services declined 

the least in neighborhoods that lost the most total household income during the Great 

Recession.

Overall, higher household income appears to be associated with positive substance use-related 

outcomes, as well as improved healthcare outcomes overall. Continued efforts to increase 

household income may bring further positive results.

Housing Status

To ensure that housing reinforces economic stability, it needs to exist, be stable, and be 

affordable. People who experience homelessness, move frequently, or spend a major portion of 

their income on housing are significantly more likely to experience a wide range of physical and 

mental health conditions. Stable and affordable housing is housing that someone can afford 

and that they are certain they can maintain.

Having housing provides shelter against numerous traumas associated with homelessness—

such as violence or extreme temperatures. Estimates of lifetime rates of experiencing 

homelessness vary, but two estimates are 4.2% or 7.4%. Stable housing can protect against 

anxieties and other mental health conditions associated with frequent moves. Affordable 

housing in the United States is generally defined as costing less than 30% of family income.

In 2021, 35% of U.S. families spent more than that amount on housing. When housing is 

unaffordable, it can reduce the ability of people to afford other costs that can improve health.

Findings from seven studies suggest that experiencing homelessness may be associated with 

substance misuse risk. Four studies found that experiencing homelessness is associated with 

increased risk of substance misuse.

Homelessness is also associated with reduced likelihood of completing substance use treatment 

programs and achieving substance use disorder remission. One study looking specifically at 

tobacco smoking found no association between smoking rates and experiencing homelessness. 

Another study found that people experiencing homelessness are more likely to possess 

naloxone—which the authors posit to be the result of the rapid expansion of naloxone access 

programs to serve this high-risk population.
9 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

Overall, having affordable, stable housing appears to be associated with decreased risk of 

substance use disorders (SUD) and improved likelihood of positive outcomes if SUD occurs. 

Efforts to reduce homelessness and expand access to affordable, stable housing may yield 

positive results.

Job Skills Training

Jobs skills training programs—also known as employment training, workforce training, career 

skills training, or vocational training—teach people relevant skills for specific professions. 

Providing relevant and useful job skills training is vital to ensuring people’s economic stability.

A wide variety of job skills training programs have shown effectiveness at reducing 

unemployment, which is associated with greater risk of physical and mental health conditions, 

including experiencing stress-related illnesses.

They are offered by a wide variety of organizations, including schools, nonprofits, employers, 

and trade associations. Some programs are specifically tailored for people with low income or 

without a high school diploma.

While there is much evidence to support the connection between SUD recovery and job skills 

training, there is insufficient research on the connections between job skills training programs 

and substance use initiation and misuse to draw conclusions. Findings from one study suggest 

that the positive impacts of job skills training programs could extend to substance misuse risk, 

specifically that participation is associated with decreased rates of illicit substance use (except 

marijuana) and binge drinking.

Diving Deeper: Research Article Summaries

Download the PDF to dive deeper into the articles related to these four SDOH and their impact 

on substance misuse-related outcomes. Each summary offers insights into the articles' key 

findings, conclusions, study demographics, methodologies, and citations. To learn more about 

our comprehensive literature review process, please see the Methodology section.
10 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

NEIGHBORHOOD AND BUILT ENVIRONMENT

About the Domain

Neighborhood and Built Environment focuses on the connections between where people live 

and their health and well-being. It considers characteristics of the many different physical and 

natural environments in which people spend time—for example, lead, mold, or other 

hazardous conditions in homes, schools, and workplaces; access to healthy and culturallyrelevant foods, parks, and transportation; air and water quality; and neighborhood and 

community safety.

Related Determinants

Within this domain, the SDOH associated with substance misuse-related outcomes include:

1. Geographic and Building Characteristics

2. Neighborhood Environmental Stress

Geographic and Building Characteristics

The physical characteristics of the environment (e.g., the level of urbanization, density of legal 

substance retail outlets, availability of safe drinking water) are vital components of the 

neighborhood and built environment. These characteristics can be natural or man-made and 

have many associations with health and well-being.

Research is still identifying all of the physical characteristics of the environment that are 

associated with health, but some examples include water quality, air quality, noise pollution, 

proximity to hazardous waste sites, frequency/intensity of severe weather events, structural 

quality of homes, and density of healthy food retailers. Some of these characteristics are also 

associated with rates of stress, anxiety, and other mental health conditions.

There is insufficient research available on the associations between geographic and building 

characteristics and substance misuse to draw conclusions. Findings from 15 studies add to the 

research base, but they examine a wide variety of distinct issues and sometimes present 

inconsistent results. Many studies examine the associations between rural or urban density and 

risk of substance misuse. Studies differed on whether more urban or rural communities have a 

greater likelihood of substance misuse risk, overdose risk, or obtaining services, depending on 

the population, substance, and other variables examined. Two studies found that a higher 

density of substance use disorder treatment providers is associated with greater likelihood of 
11 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

people with SUD considering treatment. One study found an association with drinking 

Tetrachloroethylene (PCE)-contaminated water as a child and a greater likelihood of having a 

substance use disorder as an adult.

Neighborhood Environmental Stress

Neighborhood environmental stress includes stress stemming from high crime rates, physical 

deterioration of buildings, poorly maintained streets, and perceptions of risks. Preventing and 

reducing this stress is vital to ensuring a positive neighborhood and built environment.

People living in neighborhoods with high or daily stress are more likely to experience a variety 

of physical and mental health conditions. Neighborhood environmental stress is associated with 

elevated cortisol levels, which makes people more vulnerable to disease. It is also associated 

with anxiety, reduced rates of physical activity, and greater likelihood of long-term, chronic 

health conditions.

There is insufficient research on the connections between neighborhood environmental stress 

and substance misuse to draw conclusions. Findings from two studies show that higher rates of 

neighborhood environmental stress may be associated with increased likelihood of substance 

misuse. Specific stressors identified by the studies included high homicide rates, poverty rates, 

population density, community distrust, visible substance misuse, and visible immigration and 

border control.

Diving Deeper: Research Article Summaries

Download the PDF to dive deeper into the articles related to these two SDOH and their impact 

on substance misuse-related outcomes. Each summary offers insights into the articles' key 

findings, conclusions, study demographics, methodologies, and citations. To learn more about 

our comprehensive literature review process, please see the Methodology section.
12 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

SOCIAL AND COMMUNITY CONTEXT

About the Domain

Social and Community Context considers people's interpersonal connections, including with 

family members, friends, co-workers, and other community members. It emphasizes the 

health-related benefits of social support within relationships as well as engagement 

opportunities and social cohesion within the broader community. It also emphasizes the healthrelated challenges of violence within relationships and stigma and discrimination within 

relationships and the broader community.

Related Determinants

Within this domain, the SDOH associated with substance misuse-related outcomes include:

1. Acculturation Stress

2. Adverse Childhood Experiences

3. Criminal Justice Involvement

4. Historical Trauma

5. Stigma and Discrimination

6. Social Relationships

7. State Medical Marijuana Legalization

Acculturation Stress

Acculturation stress is the stress that immigrants experience adapting to U.S. culture. 

Addressing it is vital to ensuring a healthy social and community context. Acculturation stress is 

associated with increased risk of mental health disorders and negative physical health 

conditions.

From 2010 to 2021, more than 12 million new immigrants obtained lawful permanent status in 

the United States, and more than 600,000 people obtained refuge or asylum status. Immigrants 

can experience acculturation stress from many sources, including discrimination, economic 

hardships, language barriers, lack of access to healthcare services, changes in family dynamics 

and social relationships, and trauma. Chronic exposure to all kinds of stress is associated with 
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negative physiological responses and a greater likelihood of adopting negative coping 

behaviors, both of which can lead to negative health outcomes.

There is insufficient research available on the associations between acculturation stress and 

substance misuse to draw conclusions. Findings from four new studies add to the growing 

research field. Three of the studies found that higher rates of acculturation stress among 

Hispanic/Latino immigrant communities are associated with greater risk of substance use. 

However, the fourth study—of African- and Caribbean-born Black immigrants—found that 

immigration status appeared to convey a protective factor against substance use, regardless of 

acculturation stress.

Adverse Childhood Experiences

Adverse childhood experiences (ACEs) are stressful or traumatic events that occur between the 

ages of 0 and 17. Preventing and reducing the impact of ACEs is vital to ensuring a healthy 

social and community context. ACEs can take many forms and can have physical and mental 

health effects that persist for years.

ACEs range from forms of abuse and neglect to household dysfunction and negative community 

experiences. The more ACEs a person experiences, the greater the cumulative negative impact 

on overall well-being and numerous health outcomes. In a 2018 federal study, more than 61% 

of adults reported having at least one ACE and 16% had four or more. ACEs are associated with 

greater likelihood of experiencing economic roadblocks (e.g., reduced educational attainment 

and difficulty obtaining employment), engaging in antisocial behaviors, having mental health 

disorders, and having chronic physical health conditions.

Findings from 11 studies show that ACEs are associated with greater likelihood of substance 

use, generally, and alcohol misuse, specifically. Some studies found the association of ACEs with 

substance use greater among women than men, with one study finding no relationship with 

male substance use. Another study found that ACEs were only associated with substance use 

and not alcohol misuse.

Overall, ACEs appear to be associated with negative substance use-related outcomes, as well as 

poor healthcare outcomes overall. Efforts to prevent or mitigate the effects of ACEs may yield 

improved outcomes.

Criminal Justice Involvement

Criminal justice (CJ) involvement encompasses numerous phases, from initial law enforcement 
14 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

encounters to pre-trial detention to incarceration and community supervision. Current or prior 

involvement with the CJ system can have a distinct and lasting impact on the social and 

community contexts of people. People with current CJ involvement often have significant 

healthcare needs and lack of access to services, particularly incarcerated people. Meanwhile, 

people with prior CJ involvement often face intense discrimination. This discrimination can 

significantly impact other health indicators, such as reduced likelihood of obtaining 

employment or stable housing, which can lead to increased risk of negative health outcomes.

Findings from 11 studies show that prior CJ involvement is associated with greater risk of SUD, 

overdoses, and relapse. One study found prior CJ involvement associated with reduced 

likelihood of employment, another risk factor for substance misuse. However, another study 

found that prior involvement among adolescents is associated with increased likelihood of 

completing treatment programs. A study of incarcerated people found that 43% had a 

substance use disorder diagnosis in the year prior to incarceration.

Overall, CJ involvement appears to be associated with higher odds of negative substance userelated outcomes, as well as poor healthcare outcomes overall. Efforts to address the impacts 

of CJ involvement—such as stigma—and expand treatment diversion programs may yield 

improved outcomes.

Historical Trauma

Historical trauma refers to the “cumulative, multigenerational, collective experience of 

emotional and psychological injury in communities and in descendants.” Historical trauma and 

its effects on descendants is a growing field of research that may be an important part of the 

social and community context of people.

Historical trauma can vary dramatically across populations. Research has not yet codified how 

to measure historical trauma or developed a standard body of knowledge on the health effects 

of historical trauma or its implications for service providers. However, most studies have found 

some degree of association between higher rates of historical trauma and adverse health 

outcomes.

There is insufficient research to draw conclusions about any associations between historical 

trauma and substance misuse. One study measured historical trauma among indigenous 

populations by how frequently the study participants thought about losses related to the 

trauma. It found mixed results on the association that historical trauma had with substance 

misuse risk, depending on whether thoughts of trauma led to increased depression or increased 
15 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

sense of resiliency.

Stigma and Discrimination

Stigma and discrimination are two distinct—but interrelated—concepts that can increase risk 

for substance misuse and other negative health outcomes. Stigma refers to a wide range of 

negative attitudes, values, and beliefs that manifest in prejudice and discrimination. 

Discrimination refers to unfair and unjust actions that can stem from stigma and target and 

harm people and communities. Addressing stigma and discrimination in all their various forms 

is vital to ensuring a healthy social and community context for people to live in.

Stigma takes three primary forms: public (stigma caused by other people), self (stigma from 

within ourselves), and institutional (stigma from ingrained, systematic rules and regulations). 

Discrimination takes two primary forms: structural—evident in macro-environmental 

conditions like segregated housing—and individual—found in daily experiences such as 

harassment by community members. Discrimination and stigma can adversely impact health 

through three pathways that can lead to direct physical harm as well as long-term, negative 

mental health impacts:

1. Limiting access to resources that can improve health

2. Producing stress that can harm health

3. Exposing people to violence

Findings from 24 studies show that experiencing stigma or discrimination is associated with 

increased risk of substance misuse, substance use disorder, earlier initiation of substance 

misuse, and reduced likelihood of telling others about substance misuse or about being in 

recovery from substance misuse. Stigma and fears of stigma are also associated with reduced 

access to service among people with SUD, especially among pregnant women with SUD and 

sexual and gender minority populations with SUD. By comparison, societal reductions in 

structural discrimination are associated with increased access to substance misuse treatment 

services among sexual and gender minority populations. One study found that discriminatory 

policies against pregnant women with SUD—designed to coerce treatment utilization—are not 

associated with increased treatment admissions or reduced rates of neonatal abstinence 

syndrome.

Overall, stigma and discrimination appear to be associated with negative substance misuserelated outcomes, as well as reduced healthcare outcomes overall. Continued efforts to reduce 
16 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

stigma and discrimination may bring further positive results.

Social Relationships

The relationships people have with those around them and the supports they receive through 

those relationships are core to their social and community context. Having healthy, positive 

relationships can mitigate the negative associations of other social determinants of health and 

is associated with positive mental health outcomes.

Relationships exist at the interpersonal and community/societal levels. Interpersonal 

relationships are those that people have with people in their daily lives, such as friends, family, 

peers, and coworkers. They are represented in the “Relationship” level of the socio-ecological 

model of prevention. Community/societal relationships are the collective social cohesion and 

social trust that people have with their broader community.

Research has identified numerous associations between positive relationships and higher levels 

of social cohesion with improved health outcomes.

Findings from 11 studies show that having a greater number of positive social relationships is 

associated with reduced risk of substance use disorder, overdose, or experiencing SUD 

recovery-related discrimination. One study also found positive social relationships are 

associated with a greater likelihood of completing SUD treatment.

Studies found that negative social relationships—including experiencing harassment, suffering 

from discrimination, or having a partner with a substance use disorder—are associated with 

greater risk of substance misuse. However, one study found that positive social relationships 

are not a protective factor against substance misuse among people living with HIV.

Overall, having positive social relationships appears to be associated with positive substance 

use-related outcomes, as well as improved healthcare outcomes overall. Continued efforts to 

build and support positive relationships may bring further positive results.

State Medical Marijuana Legalization

Marijuana is the third most used substance, after alcohol and tobacco. Many states have 

legalized medical marijuana use, or even all adult marijuana use, which increases access and 

availability for purchase. A potential area of concern is whether this increased access for adults 

also affects youth, despite continued bans on youth use. The legal status of medical marijuana 

use in a state is a key component of the social and community context.
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In 2021, 13% of people in the United States (ages 12 and older) used marijuana regularly (past30-day), and 5.8% had a marijuana use disorder. Marijuana use can present important health 

risks, depending on the dose and method of ingestion. Although more research is needed, 

these risks can include elevated risk of heart disease, impaired brain development among 

youth, lung damage, and impaired driving.

There is insufficient research on the associations between state medical marijuana legalization 

and marijuana use to draw conclusions. Findings from three studies suggest that state medical 

marijuana legalization may have a positive association with non-medical marijuana use. Two 

studies found that both medical and non-medical use rates are higher in states with legalized 

medical use than states without it. A third study found that marijuana-related treatment 

admissions declined more in states with legalized medical use than in states without it, but the 

study authors note that the decline was minimal and that legalization was likely not responsible 

for the decline.

Diving Deeper: Research Article Summaries

Download the PDF to dive deeper into the articles related to these seven SDOH and their 

impact on substance misuse-related outcomes. Each summary offers insights into the articles' 

key findings, conclusions, study demographics, methodologies, and citations. To learn more 

about our comprehensive literature review process, please see the Methodology section.
18 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

EDUCATION ACCESS AND QUALITY

About the Domain

Education Access and Quality considers access to opportunities that support learning and 

development during early childhood, K-12 education, vocational training, and higher and 

continuing education. It also considers the quality of all available educational opportunities, 

including how well they support academic and other educational goals as well as the physical, 

social, and emotional well-being of those involved.

Related Determinants

Within this domain, the SDOH associated with substance misuse-related outcomes include:

1. Educational Attainment

2. Educational Environment

Educational Attainment

Ensuring that people obtain a high-quality education is the core goal of expanding access to 

education. Increased educational attainment is associated with numerous positive physical and 

mental healthcare outcomes. On average, each additional “step” of education completed (e.g., 

less than high school, high school, some college) is associated with living as much as 1.37 

additional years.

Increased educational attainment can improve health outcomes through economic, social, and 

behavioral pathways. Increased educational attainment is associated with improved 

employment opportunities and household income, which can improve health outcomes. 

Greater educational attainment is also associated with better implementation of healthy coping 

strategies and stronger social supports. Greater adherence to healthy behaviors, such as 

decreased likelihood of tobacco use, is also associated with increased educational attainment. 

In fact, many studies report causal links between education and health.

Findings from 23 studies show that greater educational attainment is generally associated with 

reduced likelihood of tobacco, marijuana, or methamphetamine misuse and lower risk to 

overdose or contract HIV if substance misuse occurs. People with greater educational 

attainment are also more likely to be screened for substance misuse, linked to care if 

appropriate, and more likely to recover from substance use disorder.
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However, findings are not uniformly positive. Studies also found greater educational attainment 

associated with increased likelihood of prescription drug misuse, alcohol misuse, LSD use, and 

the use of novel psychoactive substances among some populations. One study found alcohol 

and tobacco use disorders are associated with greater educational attainment among people 

with a history of ACEs—a finding that requires further research.

Overall, greater educational attainment appears to be associated with positive substance userelated outcomes, as well as improved healthcare outcomes overall. However, despite its 

generally protective nature, educational attainment may also present potential risk factors that 

must be addressed as well.

Educational Environment

The educational environment refers to numerous components of the circumstances 

surrounding education, including the quality of teaching or training, the availability and 

perceptions of learning opportunities, the presence of social supports, and the type and volume 

of student workload. The educational environment impacts students and learning at all ages, 

from elementary school to graduate programs.

An educational environment conducive to student learning and academic achievement is vital 

to ensuring access to high-quality education. Both the educational environments and student 

perceptions of those environments are associated with student motivations, satisfaction, and 

educational attainment. Educational attainment is associated with many positive healthcare 

outcomes.

There is insufficient research on the connections between educational environments and 

substance misuse to draw conclusions. Two of four studies found that negative educational 

environment conditions—specifically, experiencing bullying or discrimination and having workschool conflicts—are associated with increased substance misuse. A third study found that 

students involved in drug transaction experiences are at increased risk of experiencing bullying, 

physical violence, and other events that can increase risk of substance misuse. The fourth study 

found that homeschooled students have a lower risk of substance misuse than other students 

who are at a high risk of dropping out of school, but a higher risk of substance misuse than 

other students who are at a low risk of dropping out.

Diving Deeper: Research Article Summaries

Download the PDF to dive deeper into the articles related to these two SDOH and their impact 

on substance misuse-related outcomes. Each summary offers insights into the articles' key 
20 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

findings, conclusions, study demographics, methodologies, and citations. To learn more about 

our comprehensive literature review process, please see the Methodology section.
21 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

HEALTH CARE ACCESS AND QUALITY

About the Domain

Health Care Access and Quality considers multiple aspects of health care access, including 

affordability, how easy it is for people to physically reach a provider or service, whether a 

provider or service has available resources (e.g., personnel, technology) and can adapt (e.g., 

appointment times, communication strategies) to meet people's needs and preferences, and 

how comfortable people feel with the provider or service. It also considers such elements of 

health care quality as the degree to which it is safe, effective, and person-centered.

Related Determinants

Within this domain, the SDOH associated with substance misuse-related outcomes include:

1. The COVID-19 Pandemic

2. Health Care Services

3. Health Insurance Coverage (All)

4. Health Insurance Coverage (Medicaid)

5. Health Insurance Parity

6. Veteran Health Care

The COVID-19 Pandemic

The COVID-19 pandemic has been extremely disruptive and had a significant effect on the 

health and well-being of people. The immediate direct health impacts are well- known, 

including 1.12 million deaths in the United States and many more cases of serious short- and 

potentially long-term physical harms. But research into the long-term health effects is just 

beginning.

The COVID-19 pandemic has been associated with increases in rates of stress, anxiety, 

depression, and domestic violence as well as delays in utilizing healthcare services—all of which 

are risk factors for negative health outcomes, including substance misuse.

National surveys of substance use—such as the National Survey on Drug Use and Health; and 

Monitoring the Future—present mixed findings on the changes in substance use rates during 
22 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

the pandemic. For example, looking at changes in past-30-day youth vaping rates from 2020 

and 2021, the National Survey on Drug Use and Health found a slight increase (from 5.1% to 

5.2%) while Monitoring the Future found a decline (from 18% to 13.3%). But fatal overdose 

rates rose dramatically during the pandemic, from 70,630 deaths in 2019 to 107,056 deaths in 

2022 (provisional). Rising overdoses suggest worsening effects from substance misuse, even if 

overall rates of misuse did not change. However, all national survey data from the pandemic 

must be interpreted with caution due to changes in data collection methodologies.

There is insufficient research available on the associations between the COVID-19 pandemic 

and substance misuse to draw conclusions. One study found that 17.5% of all adults reported 

new or increased substance use during the first year of the pandemic, including 38.8% of 

disabled adults. Overall, 64.1% of disabled adults reported adverse mental health conditions or 

substance misuse, although no pre-pandemic comparison data were reported.

Health Care Services

Ensuring that people receive high-quality, affordable, and appropriate healthcare services is the 

core of healthcare access and quality. Accessing high-quality health care in the United States 

generally requires health insurance coverage, and having coverage is associated with improved 

health outcomes. But lack of insurance coverage is not the only barrier to service access. 

Overcoming other barriers to healthcare access is associated with improved health outcomes.

A wide variety of factors can all hinder access to healthcare services, including resources in the 

community (e.g., workforce shortages), transportation, Internet access, community or provider 

stigma, work or school flexibility, and cost.

Findings from 17 studies show that barriers to accessing healthcare services— particularly SUD 

treatment services—are associated with greater risk of substance misuse, SUD, hospital 

emergency department visits, and overdose. Studies identified stigma, affordability, 

transportation, lack of referrals, lack of telemedicine use, and lack of a trained workforce as key 

barriers to SUD treatment. One study found that syringe exchange programs are associated 

with reduced risk of needle sharing while another found that use of community-based 

prevention programs is associated with reduced rates of prescription drug misuse.

Overall, expanding access to healthcare services appears to be associated with higher odds of 

positive substance use-related outcomes, as well as better overall healthcare outcomes. Efforts 

to further expand access to care may yield further improved outcomes.
23 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

Health Insurance Coverage (All)

Health insurance coverage is the primary mechanism for improving the affordability of 

healthcare services in the United States and is associated with improved health outcomes. As a 

result, enrollment in health insurance is vital to ensuring access to high-quality healthcare 

services. People without health insurance are less likely to see a healthcare provider and more 

likely to have difficulty affording their care.

U.S. health insurance is available through many sources. In 2021, 48.5% of people were 

enrolled in employer-sponsored coverage, 21.1% in Medicaid, 14.3% in Medicare, 6.1% in 

individual/nongroup coverage, 1.3% in military coverage, and 8.6% were uninsured. 

Uninsurance varies significantly by state, from 2.5% to 18%.

Findings from 18 studies show that having health insurance is associated with reduced 

likelihood of tobacco or methamphetamine use, greater likelihood of receiving a substance 

misuse screening or being referred to treatment services, and greater access to treatment 

services. It is also associated with reduced rates of overdoses and reduced likelihood of opioidrelated infective endocarditis. One study also found that enrollment reforms, such as the 

Affordable Care Act (ACA), led to an expansion in coverage among people with SUD and other 

behavioral health needs. However, these findings are not uniform. Some studies found that 

insurance coverage is only associated with increased availability of services and not with service 

utilization. In addition, one study found that people with health insurance are less likely to have 

access to naloxone than people without insurance.

Overall, health insurance enrollment appears to be associated with positive substance userelated outcomes and improved healthcare outcomes overall. Continued efforts to expand 

enrollment and coverage may bring further positive results.

Health Insurance Coverage (Medicaid)

Health insurance coverage is the primary mechanism for improving the affordability of 

healthcare services in the United States and is associated with improved health outcomes. 

Medicaid is a joint federal—state health insurance program that provides coverage to eligible 

low-income adults, children, pregnant women, elderly adults, and people with disabilities. 

Enrollment in health insurance, including Medicaid for those eligible, is vital to ensuring access 

to high-quality healthcare services. People without health insurance are less likely to see a 

healthcare provider and more likely to have difficulty affording their care.

Together with the Children’s Health Insurance Program, another joint federal—state program
24 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

that is run both within and alongside Medicaid, Medicaid insured 92.3 million individuals in 

2022. The federal government sets baseline standards for Medicaid coverage and eligibility, but 

states have significant leeway in shaping their programs.

Findings from 19 studies show that Medicaid enrollment is associated with increased 

healthcare utilization, improvements in self-perceived behavioral health, decreased risk of fatal 

opioid overdose, and increased likelihood of receiving substance misuse treatment or smoking 

cessation services. Medicaid coverage and enrollment reforms— such as the ACA, and the 

Mental Health Parity and Addiction Equity Act (MHPAEA)—are associated with increased 

availability and utilization of substance misuse specialty care providers. However, these findings 

are not uniform. Some studies found that insurance coverage is only associated with increased 

availability of services and not with service utilization. In addition, one study found that people 

with health insurance are less likely to have access to naloxone than people without insurance.

Overall, Medicaid enrollment appears to be associated with positive substance use-related 

outcomes and improved overall health outcomes. Continued efforts to expand Medicaid 

enrollment and coverage may bring further positive results.

Health Insurance Parity

“Parity” refers to equal coverage of behavioral and physical health services by health insurance 

plans. Implementing and enforcing parity is vital to ensuring access to comprehensive, highquality healthcare services. Historically, lack of parity has been associated with increased costs 

for behavioral health services compared to physical health services and greater disparities in 

outcomes.

State and federal law are both involved in mandating behavioral health parity. Federal parity 

standards have been implemented through a series of legislative acts starting in 1996. 

Together, the ACA, MHPAEA, and other parity laws require many health insurance plans to 

cover behavioral health services and ensure that coverage is comparable to physical health 

coverage. When implemented and enforced, parity laws can significantly improve coverage of 

behavioral health services. However, ongoing challenges have blunted their impact.

There is insufficient research to draw conclusions on the connections between health insurance 

parity and substance misuse. Three studies found that parity is associated with increased 

insurance coverage of SUD treatment, increased rates of SUD treatment facilities accepting 

Medicaid coverage, and increased adolescent admissions to substance use treatment services. 

However, a fourth study found no increase in SUD identification, treatment admissions, or 
25 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

treatment engagement in the first year after implementation of MHPAEA.

Veteran Health Care

Veterans served in active duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard. 

They face an increased risk for numerous physical and behavioral health issues that stem from 

their service history. Veterans are eligible for healthcare services through the U.S. Department 

of Veterans Affairs (VA). The VA’s Veterans Health Administration provides physical and mental 

health services at 1,298 facilities nationwide. Research shows that VA healthcare providers 

generally improve health outcomes for veterans.

The United States has roughly 19 million living veterans, who collectively face an increased risk 

of healthcare issues, including mental health conditions. Veterans with combat experience face 

an even greater risk. Comprehensive healthcare services for veterans are vital components to 

ensuring access to high-quality healthcare services.

There is insufficient research on the connections between veteran health care and substance 

misuse risk to draw conclusions. Findings from four studies add to the growing body of 

evidence. One study found that increasing VA funding for substance misuse treatment is 

associated with increased access and quality of services. Another found that veterans who 

successfully completed treatment are less likely to relapse than veterans who left treatment 

before completing it. A third study found that two-thirds of veterans with opioid use disorder 

have not received treatment services, suggesting a need for more services. A fourth study 

found that a dedicated alcohol use disorder screening program for transgender veterans did 

not increase access to treatment services.

Diving Deeper: Research Article Summaries

Download the PDF to dive deeper into the articles related to these six SDOH and their impact 

on substance misuse-related outcomes. Each summary offers insights into the articles' key 

findings, conclusions, study demographics, methodologies, and citations. To learn more about 

our comprehensive literature review process, please see the Methodology section.
26 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

METHODOLOGY

This product was informed by a multipronged literature review intended to capture the latest in 

peer-reviewed academic-published research and government and nonprofit publications and 

databases. The sequence of steps in this process is detailed below:

Step 1. Initial Scoping Review 

This review began with a scoping search of EBSCO using the following combined free text 

search terms:

• “social determinants” OR “social determinants of health” 

• AND “substance misuse” OR “substance abuse” OR “substance use disorder” OR “drug 

use” OR “drug abuse” 

Step 2. Identifying Main Review Search Terms 

This initial scoping review identified 42 articles, which were reviewed to assess the state of 

research and identify the search terms for the main review. The resulting identified free text 

search terms follows:

• “economic security” OR "education*" OR "unemploy*" OR “food security” OR 

“neighborhood safety” OR “housing security” OR “adverse childhood experiences” OR 

“discrimination” OR “health care access” OR “health care quality” OR “insurance 

coverage” 

• AND “substance misuse” OR “substance abuse” OR “substance use disorder” OR “drug 

use” OR “drug abuse” 

Step 3. Refining the Research Pool

Results were restricted to peer-reviewed studies or articles published in English from 2013 to 

2023, conducted in the United States, and that were not book reviews or dissertations. 

This search identified 495 articles that underwent abstract review. 

Step 4. Abstract Review Criteria and Outcomes 

Abstracts were assessed for
27 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

1. adherence to search parameters, 

2. confirmation of quantitative research, 

3. examination of social determinants of health (SDOH) indicators in the study design, 

and 

4. reported results relevant to substance misuse outcomes. 

This abstract review identified 179 articles as meeting all four criteria.

Step 5: Full Text Review and Final Article Selection

Full texts of 168 articles were obtained. The remaining 11 articles were not able to be obtained. 

However, another review of their abstracts determined that their findings were likely replicated 

by other articles among the 168 obtained articles. 

The obtained articles had their full texts assessed under the same criteria as the abstract 

review.

Step 6. Extraction and Analysis of Findings

Information on the findings and results, evaluation conclusions, populations studied, study 

setting, and study design was extracted from each of the 121 articles.

Article results were examined to identify themes in studied SDOH topics. These themes were 

further condensed based on their similarities to create 24 categories, or 'indicators,' of the five 

core SDOH domains organized by the HHS. The articles’ findings were also translated into 49 

distinct substance misuse-related outcomes. Articles were organized into each indicator 

relevant to their findings, with many articles appearing in multiple indicators as studies often 

examined more than one. Each indicator was examined in a detailed and interconnected 

manner to identify common findings across articles; these are reported on the indicator pages 

within their respective domain section. Full extraction results of each article, along with 

citations, are available through the PDFs at the end of each domain section.
28 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

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31 | INCORPORATING THE SOCIAL DETERMINANTS OF HEALTH INTO SUBSTANCE USE PREVENTION 

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