The opioid crisis continues to expand into suburbs and more affluent areas, and now we\u2019ve started to hear the message that \u201caddiction doesn\u2019t discriminate.\u201d The statement is meant to showcase that addiction can affect people regardless of economic status, to change the way we view those struggling with addiction.\u00a0 On the one hand, this is correct. Addiction CAN affect anyone, just like, technically, anyone CAN become president. For too long, and even today, after all that\u2019s been done to fight stigma, many Americans still have a picture of those struggling with addiction as poor, unemployed, homeless, and weak-willed. It\u2019s important we remember that, of 23.1 million people struggling with addiction annually, most of them have jobs, families, hobbies, and look like anyone else you\u2019d meet outside on the street. Where the message that \u201caddiction doesn\u2019t discriminate\u201d goes astray is that addiction does affect those struggling to get by or who find themselves in the middle working class, much more so than those coming from higher income brackets. And this is critically important for us to understand if we\u2019re going to help everyone who is struggling with addiction. Effective addiction treatment must be tailored to specific individuals and their backgrounds. We often like to say that, \u201cto help someone get out of addiction, you first have to understand how they got in.\u201d Addiction treatment is not one-size-fits-all, and how you treat it will depend on why people ended up addicted initially. This is a huge problem because most private rehabs have catered to higher-income demographics, those who have out-of-network private insurance with low deductibles or those who can afford to pay tens of thousands of dollars a month.\u00a0 But the lawyer making $300,000 a year who drinks daily to relieve stress, or the son of a wealthy businessman who takes pills to rebel against his father and numb feelings of never being good enough, are different from the average person who got addicted to pain pills after a work injury or the guy on the construction crew who recognizes his problem of going to the bar nightly after work because that\u2019s what everyone else does. So let\u2019s take a look at what the data and research say about how the availability of and access to resources impact addiction rates because, if we can understand some of the factors causing addiction, we can develop better treatments to help people find recovery. And, remember before moving forward, there are many factors that influence addiction - biology, life experience, and culture to name a few. Most information out there focuses on biology, but that is simply one piece of a more complicated picture that we need to explore. Our knee-jerk reaction as a society is to assume that the only ones impacted by drug and alcohol abuse are those who are low-income, homeless, or simply lazy. We also find many of us assume those with tons of money are also struggling with addiction because they\u2019ve got so much money they have nothing else to do. Part of this could be because those in lower socioeconomic standing are more likely to self-identify their drug use and the fact that so many of these stories are highly publicized.\u00a0 Socioeconomic status, or our total measure of social status and economic standing, affects all parts of our health. It is built of three main pieces: income, job status, and education. In the United States, there are actually 12 socioeconomic classes which are broadly categorized as high, middle, and low. These 12 socioeconomic groups are built by looking at the big three pieces alongside many smaller pieces. A common misconception is that when someone says socioeconomic status, it means income or how much money you have in your bank account. Take your average high school chemistry teacher, for example, this teacher has moderate to low income, high education level, and job security. So they would be in the middle socioeconomic class. Socioeconomic status, or SES, impacts so many other factors of our lives than just our income. The impacts of SES can be positive or negative, big or small. How Does Socioeconomic Status Influence Addiction? Everyone has different experiences, so an important but often overlooked aspect of addiction is looking at it through a lens that focuses on income and SES disparities in the US. This way, we can understand where addiction pathways begin. A study by the University of Michigan set out to explore just this issue. They focused on the three main pieces of socioeconomic status (SES): income wealth, job status, and education. They found all three pieces of SES were associated with substance abuse and addiction in their own way.\u00a0 Generally speaking, lower SES relates to higher rates of prevalence of smoking, including marijuana, and other drug based addictions, while, at the same time higher SES relates more to frequent drinking, although not necessarily addiction.\u00a0 \u00a0A study done by the National Center for Biotechnology Information, a leader in addiction and mental health research, found that the young adults from affluent families were more prone to alcohol and marijuana use. And they were not the only study to find this type of connection, another study by the University of Washington found similar relationships between socioeconomic status (SES) and drug use among teenagers and young adults.\u00a0 Now, what\u2019s interesting and often overlooked is that even though higher SES related to more frequent drinking there was less alcoholism. Studies suggest this could be for many reasons, one of which is that usually, when young adults come from affluent families, they go on to attend college. In college years, it is common to see students testing a variety of things because they have more freedom from their parents, and they are trying to find a new social circle. So, while these students may have higher rates of use, they are the norm is that drug use doesn\u2019t lead to addiction. Only a small minority move on to abusive or addictive use because they do not often lead to addiction. Often times as they near graduation, students will start to \u201cmature out\u201d of these types of behaviors. One study suggests this is related to the ability to find and secure a full-time position after graduation and,m as students begin to join the workforce their high use of stimulant drugs and alcohol tends to decrease rapidly. Yet, often those with higher SES are more likely to use alcohol and drugs than those in lower SES on a more regular basis, but not become addicted to them.\u00a0 A study completed in Germany, found parents in families with lower SES were more likely to avoid alcohol use totally. While we notice a trend that is similar in the U.S., it is more likely that those making less than $50,000 a year are less likely to drink in general, but when they do, they binge drink (5 or more drinks per sitting), and have higher rates of alcoholism. Other research states that types of usage can be related to the cause of stress. For example, lower SES can be linked with stress about finances and higher SES stress is less often surrounding money. It is also noted youth from less advantaged households end up more likely to also be impacted by stressors at a younger age. Those who have more access tend to use more regularly but they also have different stressors and reasons for use than those who have less regular access. Think of the lawyer and the average worker that we talked about before, each use substances but one of them is more likely to become diagnosed with a substance use disorder. So, the next reasonable question is why? Why do we see addiction rates vary at each level? Why do those that struggle to get by, end up more likely to struggle with addiction as well? Remember, the pathway to addiction is more than only economic status, income, and employment; it is also stress, experiences, trauma, genetic influences, cultural background, and peer pressure.\u00a0 While addiction rates are higher in those with lower SES, it does not mean that they are the only ones impacted. Those living above the poverty line in the middle class are also likely to be impacted by substance use disorders.\u00a0 What About the Middle Working Class? Drug and alcohol addiction crosses all socioeconomic lines and the middle working class is no different. The working class lands in the broad middle of high SES and low SES. They also fall into a unique category of social acceptance of binge drinking and drug use in younger ages that is not found in other settings. This is also the largest socioeconomic group, accounting for six of the twelve classes found in the United States. Yet it does not typically get mentioned when discussing substance use disorders.\u00a0 Those in the working class typically have at least one to two people in the household having some form of formal education, either via university, trade schools, or a high school diploma. According to the Institute of Family Studies (IFS), working-class and middle-class Americans are in more unstable family settings than those from affluent families. The IFS suggests some of this can be because of lower marriage rates, higher rates of divorce, and lack of resources. Young adults growing up in middle-class homes are usually found to be more likely to sample or use alcohol or drugs while they are in high school and college than those from outside the middle class. Also, those with well-educated parents are more likely to engage in alcohol, marijuana, and cocaine use as young adults versus those with less-educated parents. This could be in part from the culture of the community. Remember, many middle and working-class families send their children to college and universities which opens a new world of possibilities and temptations. It is also likely that schools and counselors are not even considering addressing this problem simply because they don\u2019t know it needs to be done. As research progresses, it continues to show trends that match the middle class to a higher risk for substance use disorders. As stated above, the journey to addiction does not only come from income level or usage, it also comes from the stressors in our lives and for the working-class, these stressors are at an all-time high. It is no surprise that the middle working class is a group that is at higher risk for substance abuse disorders than those with higher SES when you consider it is not only the largest socioeconomic group but also it is a perfect storm of risks and access.\u00a0 A study shows 25% of young adults from middle-class homes engaged in binge drinking, 24% engaged in marijuana use, 4% in cocaine use, 1% in crystal methamphetamine use and 5% in other drug use during early adulthood. These numbers can be surprising for many of us and the study from Arizona State University found that as many as 23-40% of men and 19-24% of women from middle-class families can meet the criteria for substance dependence diagnosis before age 27.\u00a0 We see these types of numbers more frequently in recent research because, in part, more and more of middle-class young adults are maturing out of usage habits less quickly than in the past. This is also deeply connected to some other pieces we\u2019ve discussed like family life, experiences and the acceptance by peers.\u00a0 It is clear we need to reevaluate the way we look at substance use disorders and who they impact. We need to work to understand that use is not the only piece of the puzzle that makes up addiction. In most cases, it is more than simple use that leads a person to a substance use disorder. Some of these other driving factors are related entirely to SES including stressors, the culture of use, the likelihood of trauma in the past, and less access to healthy outlets for stress. What Can We Do? We can start by addressing the average person more often when it comes to substance use disorder policies. Currently, most policies and programs seem to target only the poorest among us, while private treatment programs only target the ones with the most means. Programs and policies need to be sure to assess treatment is provided to the average person using Medicaid, HMOs, or other in-network insurance. We need to address treatment differently for those coming from different backgrounds. As we\u2019ve noticed through all the latest data and trends, addiction can impact anyone but it is far more likely to impact those of us with a perfect storm of socioeconomic status, stressors, culture of use and past trauma. It is not solely those who struggle to pay the bills or those who struggle to keep a job or even merely those who have limited education.\u00a0 We need to start working towards understanding that everyone is different whether it be from socioeconomic status or experiences. To help someone find recovery, you first need to understand the path that led them to addiction. It is important to understand that everyone is unique, and may be facing their own stressors.\u00a0 Programs and policies need to be tailored for each person rather than adopting a one size that fits all approach. Any care program designed to facilitate the recovery journey needs to provide you with opportunities to learn, grow, share and customize your needs throughout. Recovery is unique to everyone and no one\u2019s journey will look identical to anyone else's, so why should their treatment programs? At Promises, we believe the middle class has been overlooked for too long in the discussions surrounding addiction, and we work to provide a facility that focuses on this unique demographic. We seek to help those of every means.