Social Determinants and Drug Dependence: Systematic Review of Literature

ABSTRACT A systematic literature review on social determinations and consumption of psychoactive substances was realized. The research was accomplished in some databases, in Portuguese, English and Spanish, using the descriptors "Social Determinants in Health" and the Boolean descriptor AND for the term "Disorders Related to Substance Use". Then, 78 articles were selected, in which a concentration of studies was observed in the northern hemisphere, emphasizing on micro social factors. The most studied drugs were multiple substances (44.9%), alcohol (21.8%) and tobacco (15.4%), highlighting the determinants of income (35.9%), sex, family and territory (26.9% each). It is important to consider drug use as a complex and multifaceted biopsychosocial phenomenon, requiring greater production of evidence in developing countries, using different epistemological and methodological perspectives.

The problems related to psychoactive substance use are widely known as one of the main public health challenges in the world.It is estimated that about 271 million people have used these substances at least once, and that around 35 million suffer from complications related to substance use (United Nations Office on Drugs and Crime [UNODC], 2019).In Brazil, specifically, an estimated 11.7% of the population has used alcohol and tobacco and around 2.6% has used alcohol and other illegal substances in the last 12 months (Bastos, 2017).Beyond the data about use and dependence, the theme relates to physical, psychological and socioeconomic damage, causing meaningful impact to the personal, academic, professional, social and family lives of users.According to the World Health Organization (WHO), 8.9% of the global share of illnesses are related to the use of such substances (World Health Organization [WHO], 2018).This data, associated with other consequences in terms of mental health, indicate that psychoactive substance abuse and dependence is a phenomenon of a complex biopsychosocial nature with many faces.
Drug dependence is considered a chronic health condition, understood from a continuous pattern of previous consumption that won't necessarily lead to dependence or harm, with a perspective that considers different sociocultural and sanitary aspects for a more dynamic and complex understanding (Mota, Ronzani, Tófoli & Rush, 2015).In this way, it is understood and highlighted that not every consumption of any substance is automatically pathological, but that it does demand a wide and careful evaluation about this condition.Thus, although a smaller percentage of users will develop Substance Use Disorders throughout life, it is necessary to evaluate the different impacts of this condition to the lives of individuals and society (Volkov et. al., 2017).
In this direction, in regard to the organization of mental health care from an integral perspective, it is considered that one must start not just from the understanding of substance use and the relationship of individual and groups with drugs as a historical fact, but its articulation with sociocultural context's characteristics and its subjective dimension.Drug use is understood in its interaction among drug-individualcontext, which gives real meaning to the problems related to this practice (Ronzani, 2018).Thus, it's fundamental to understand that substance use is related to a wider plot of social determinations.While the use of drugs is present in all social classes and in different contexts, the social load or illness related to this use is very different when taking into account social belongings, gender issues, race/ethnicity, age, among others (Wilkinson & Marmot, 2003).
The understanding of the health-illness process, from the social determination paradigm, therefore, aims to broaden the horizons of our understanding of this process, which traditionally focuses on biologic and individual agents (Rocha & David, 2015).This perspective begun from the discussion about Social Determinants of Health (SSH -DSS in the original Portuguese), which mean, life conditions, economic, social, cultural, ethnic/racial, psychological and behavioral factors that influenced the creation and maintenance of health conditions, and that determine some barriers to care access, creating inequalities (Allen et al., 2014;Buss & Pellegrini, 2007;WHO, 2010).
From this initial conception, this area of knowledge and research was developed, diversified and emphasized new ways to understand Social Determinants of Health (Buss & Pellegrini, 2007).Some of them maintain the classical epistemological tradition that, although there are some variables in health condition determinants that must be taken into consideration, they establishes direct and definitive correlations, creating a static and fragmented portrait of reality (Rocha & David, 2015;Spooner, 2009;WHO, 2010).Other epistemological branches, based in social theories, seek to understand the health-illness process as determined by history, culture and social issues in many levels, in a processual and complex manner (WHO, 2010).Furthermore, it seeks to understand how these elements relate to each other and how certain health conditions are produced, how they are interpreted by the population and what actions are planned for their improvement or maintenance (United Nations Development Programme [UNDP], 2013).
Therefore, considering the historical complexity among some social, economic and cultural factors in a procedural and historical manner, some authors sought to differentiate themselves from the theory of social determinants, anchored in classical epistemology, and began using the term Social Determination (Rocha & David, 2015).Such perspective considers, according to Dimenstein et al. (2017), that it is vital to a wide understanding of the health-illnesses process that one identifies the history, the intricacies and inequalities produced by a specific society model, creating concrete impacts in the lives of people and in the way how health conditions are faced by the collective.Therefore, the simple analysis of correlation of social factors, in different levels, becomes limited (Dimenstein et al., 2017;Rocha & David, 2015).
When it comes to mental health, the importance of social determination lenses to guide our gaze is crucial, because hegemonically, mental suffering is treated as something of an individual character and disconnected of social, economic, cultural, political and environmental aspects (Dimenstein et al., 2017;Allen et al., 2014).More specifically on dependence to alcohol, tobacco and other drugs, evidence shows that social context is a determinant, not only in the way that the population perceives such a condition but also in how it interprets and develops public policies from many shared beliefs (Ronzani, 2018).Thus, many punishment-based actions, which exclude and individualize, are proposed as a consequence, for instance, of the structural stigma that exists for users (Livingston, 2013).Research that relates elements of the users' lives context and their consumption of drugs focus on the territorial characteristics and how they help to understand the impact of substance dependence among certain groups, through comprehensive and dynamic perspectives (Galea et al., 2005).
Thus, a lot of criticism has been made to the epistemological perspective of how Social Determinants of Health are handled when it comes to drugs, which is still based in an understanding of the user's behavior as an isolated event, individualized, without taking in consideration the social context, territory, family, issues of income, poverty and culture, in a procedural and complex manner (Spooner, 2005).It becomes necessary, beyond the view of the individual, to understand that there is not a single pattern of use, that related issues do not come about in the same way and that some groups, with specific characteristics, will be disproportionately more exposed to risks and damages associated with this behavior than others.Furthermore, such risks and harms should not be understood as an instantaneous and static event, but as a result of a complex interaction of many social determinants (Spooner, 2009).
Despite the importance of this paradigm shift brought by the social determination of health perspective, including to the wider understanding about drug addiction between people and populations, this is an area still relatively incipient of scientific production.Therefore, the systematization and analysis on the accumulated knowledge about the theme become relevant.In this way, the present article is a fruit of a systematic review of the literature on social determinants of health and psychoactive substances addiction, which has an aim to present the state of the art and gaps on the theme.

METHOD
The systematic review was done according to the steps indicated by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Liberati et al., 2012).The search was done in March, 2020, without a timeframe, though the year of 2019 was established as the finishing point.In order to cover the largest possible number of studies, we researched the following databases: PubMed, PsycINFO, Scielo, PEPSIC, LILACS, SCOPUS e Social Science Citation Index with the following descriptors: "Social Determinants of Health" and the boolean descriptor for the term "Substance Use Related Disorders''.The terms were defined by the dictionary of Health Descriptors (DeCS) and MeSH (Medical Subject Headings), the main vocabulary of terms used by scientific publications across the world.The choice for the search terms is justified, first of all, by the central aim of the study being Social Determinants of Health and those being the constant term in the database of health descriptors.The second choice was defined by other more general terms that did not come up in database searches and because our focus in this study is to analyze the more serious conditions of drug use patterns.The search was also done with the same terms in English and Spanish.Narrative and systematic reviews were excluded as well as metanalysis.Empirical studies were included, if their central focus was the analysis of the social determinants associated with addiction to psychoactive substances.Initially, the title of the articles was used for triage.After this stage, the abstracts were read and those that could match the inclusion criteria were evaluated by three independent researchers.
The Zotero Platform was used to organize and compile the imported data from different databases.Descriptive variables such as database, language, country of origin, publication year, methodological design (quantitative, qualitative or mixed methods), publication name and predominant knowledge areas were defined through qualitative analysis.
After this stage, a new categorization was done by more than one team researcher reading and validating the articles in full.The new categorization was of: studied population, the analyzed social determinants and the main conclusions.
After this initial stage of data handling, some variables were categorized once more as to give rise to some analysis and comparisons.The countries were organized by geographic locations or continents and, later, classified in terms of their Human Development Index (HDI) (Programa das Nações Unidas para o Desenvolvimento [PNUD], 2020) as to analyze researches previously made about the theme in different social realities across the world.The social determinants presented in the results and the research conclusions lead to their classifications in two modalities: those which associated risk or vulnerability in relation to the use of alcohol and those which presented it as protection factors.Such determinants were classified as micro, meso or macro social, according to the Dahlgren and Whitehead model (Buss & Pellegrini, 2007), which classified the Social Determinants of Health in different layers, with the more central ones being the ones considered of individual/ biological levels such as sex, age and genetic factors, and the more distant ones, the macrosocial factors such as socioeconomic, cultural and environmental conditions (Buss & Pellegrini, 2007;Rocha & David, 2015).Despite the criticisms to this model, which disregards the historical and social construction of the levels of Social Determinants of Health (WHO, 2010) and in virtue of the great diversity of epistemological perspectives presented by the selected articles, some choices were made: we used the sex (and not gender) variable, race/ethnicity were classified, according to the proposal detailed above, as micro social variables, as most studies treat them, which is to say, biological and/ or individual categories.
In terms of analysis and comparisons, we crossed the variables, giving special attention to the relationship between the type of substance, the group being studied, the discussed determinants and the classifications of the countries in terms of HDI.At last, we selected the articles that used qualitative approaches and described the main discussions and considerations from the results found in the research.The justification for this analysis is to allow us to go deeper into the works and present how the studies with qualitative approaches have treated or understood the theme of social determinations and psychoactive substance use.
After downloading and organizing the articles in the Zotero Platform, the categorizations were done through an Excel spreadsheet and exported for analysis through the SPSS software, version 15.0.The analysis was made through the frequency and category percentage.The search, selection and analysis processes of the works are described in Figure 1.

RESULTS
The electronic search through databases resulted in 905 articles distributed as follows: PUBMED (592), Scopus (167), Social Science Citation Index (138), PsycInfo (4), Scielo (2) and LILACS (2).After checking for double occurrences, there were 693 articles left.Reading their titles and abstract, based on the inclusion and exclusion criteria, the total was reduced to 105 researches.In this stage, all text was read in full.From that, 27 articles were excluded as they did not meet the inclusion criteria, resulting in 78 electable articles for review (see Figure 1).
In regards to the number of articles by publication year, publications are concentrated in the period from 2011 and beyond (5 articles).Furthermore, the years 2013, 2015, 2017 and 2018 (with 8 articles each) were those which registered the most frequent publications in the area (Figure 2).
The articles were published both in journals which dealt specifically with drugs (51.3%), and those that focused on health generally (48.7%).Referring to the methodology design, a quantitative approach was predominant (88.5%), with only 9.0% of qualitative studies and 2.6% of mixed methods (quali/quanti).It was also possible to observe more frequency in research done in North America (44.9%), followed by Europe (19.2%),Asia (16.7%),Africa (9.0%), Latin America (7.7%) and, lastly, Oceania (2.6%).There was a higher concentration of studies in countries with a high HDI (64.1%), followed by countries with average (24.4%) and low rates (5.1%) (Table 1).Furthermore, the United States was the country with the highest production concentration, with 33% of the publications, representing the highest percentage of research, with a bigger production than that of the countries of Latin America and Africa put together.Only 3 studies (3.8%) took place in Brazil, with 2 of them being quantitative and 1 qualitative.There were multiple studied substances: drugs (1), crack (1) and alcohol (1).Two Brazilian studies were done among the general population and with youths.The studied determinants were family, race/ ethnicity, immigration, health conditions, education levels, gender and income.
As for the kind of substance studied, the study of multiple drugs (44.9%) was a point of focus.Alcohol, tobacco and opiates were among the most studied substances.Among the target population of each research, the general population, usually defined through population studies of an epistemological nature, with a demographic definition, was the most frequent choice (50%), followed by youths (23.1%) and women (9%).The most studied were income (35.9%),family, gender and territory (with 26.9% each), age (23.1%), ethnicity/race (21.8%) and health conditions, as shown by Table 2.As described in the method section, an analysis was made between the social determinants and factors related to the impact of the use of psychoactive substances.In Table 3 the results are presented in regard to social determinants associated with larger harms of negative impacts in relation to drug use, classified by macro, meso and micro social levels.The frequency of association between the factors was presented like this: Microsocial (36.5%),Macrosocial (32.8%) and Mesosocial (30.7%).Among macrosocial determinants, specifically, income/ poverty (13.9%), unemployment (10.3%), stigma (3.6%), housing (3.6%) and violence (1.5%) were the most frequent ones for the association of damages connected to drug use.In a meso social level, the environment/territory (11.7%), family characteristics (13.3%), education levels (6.6%) and incarceration (2.1%) were the most frequent ones.At last, at a micro social level, the biggest association was sex (8.7%), life events (8.0%), race/ethnicity (7.3%), age (7.3%), marital status (4.4%) and religion/spirituality (0.7%) (Table 3).
Table 4 presents the results of the association between social determinants as factors that protect or relate to a smaller level of harms in relation to the use of psychoactive substances.The mesossocial level (46.4%) was the most frequent one, followed by the microsocial one (32.1%)and the macrosocial (21.5%).Employment (10.6%), social policy (7.1%), and income (3.6%) were the most frequent determinants on the macrosocial level.On the microsocial level, the most frequent categories were support/cohesions/ social networks (21.4%), family characteristics (17.9%), education level (3.6%) and protective environment/territory (3.6%).In the microsocial level, religion/spirituality (17.9%), race/ethnicity (7.1%), marital status (3.6%) and wellness (3.6%) were the most frequent ones.
At last, we compared the classification of countries in terms of HDI and other categories, such as the type of substance, group and the studied social determinations, level of determinations and the types of outcomes (positive or negative).We could not find any difference for this analysis.

For a Dynamic in the Social Determinations about Drugs: What the Qualitative articles Discuss
As previously pointed out, although the aim of the present article is not centered in the conceptual/epistemological difference between social determinants and determinations in health, we sought, although superficially, to point out this aspect.Not by accident, we used both terms, specially to show the difference when we present the results of our research.In this way, despite the limitations which will be discussed later, we highlighted the present section with the aim to bring up some studies which seek to discuss drug dependence from the perspective of social determinations.
Three articles touched on the issue of gender, more specifically, the consumption of substances among women.The study by Shahram et al. (2017), among the First Nations of Canada, point out that in issues of gender, such as motherhood, female care work overload and the social inequality conditions, such as access to education, housing and proper nutrition, as well the absence of cultural knowledge were strongly connected to substance abuse.The use of alcohol and other drugs acts as a coping mechanism to many sorrows, losses, stressful situations and overwork which these women were subject to.Furthermore, the articles discuss the family relationships which can both protect from or encourage use of these substances.Spirituality is also present as a protection factor.
Another study, done in Kenya, discusses the stigmas attached to women doing drugs.This stigma cuts through many aspects such as poverty and their condition as HIV positive, which has a direct impact in the lives of these women, creating barriers to care access (Mburu et al., 2018).Research with Canadian women points out the importance of considering many determinations in drug use, such as territory, housing, nutrition, family, and physical and mental health.
Four articles held studies with youths.In a general manner, the researches called their attention to the social norms created between the interactions of the group with their peers, family members and context where they live.The article by Yassin et al. (2018), with Lebanese youths about alcohol consumption discusses the need to understand many determinations that interact among each other to understand the context of use among this group, such as family, territory and social approval among their peers.The globalization and westernization of the culture present in the country is highlighted, changing the perception and the behavior of young people dealing with alcohol use.Another study with Dutch youths brings up the importance of group influence in establishing social norms for alcohol consumption and also adds possible factors that could diminish the use such as parental disapproval, religious or sports practices or health problems (Jander et al., 2013).The Mirlashari et al. (2013) study with Iranian youths discusses social approval and substance use as cognitively built during early development, beyond peer pressure and aspect of family and cultural life, as well as the amount of environmental stimuli that make young people vulnerable to drug use.
Lastly, a study held in Brazil sought to understand some of the barriers present for youths using crack when seeking help.The biggest complaints were long time waitingfor care, prejudice and hostile attitudes by health professionals, excessive bureaucracy and the high cost of transportation to reach locations where care is provided.They also point to a care offer that does not understand their context and is too standardized as a strong barrier when accessing treatment (Cruz et al., 2013).
The present article makes a compilation and analyzes scientific production in relation to social determinants and dependence to psychoactive substances.The data show that this is an area where international interest has grown in the most recent years, which shows how recent the discussion on the theme is, as well as shows the progressive relevance that complex approaches on social determination and alcohol use have gained in the scientific field (Spooner, 2009).
Furthermore, it is valid to bring up the fact that there is a concentration of publications in certain regions and countries, especially those in the northern hemisphere, which have higher economic development.This dynamic is present in other knowledge areas, which indicates the hegemony of these regions, both in regards to scientific knowledge production and to the capacity to broader reach of it (Crew, 2019).It is not coincidence that the present literature review shows that the theme's production is concentrated in the United States, with a higher percentage of research than Latin America and Africa put together, despite the two regions being poorer and more socially unequal, elements which gives substance abuse different implications (Organização dos Estados Americanos [OEA], sd).
In this regard, considering the importance of social determinations in the issue of drug use for a wider understanding of the theme, it is of the utmost importance that the specificities of impoverished regions can be investigated and divulged, once these contexts have a larger impact in the social matters of health (OEA, sd).Lastly, it cannot be disregarded that the characteristics of the results found in this study are due to concentration of publications in more developed countries, exposing the intimate connection Psic.: Teor.e Pesq., Brasília, 2023, v. 39, e39407 Social Determinants and Drug Dependence between a development, knowledge production and scientific market patterns.
With relation to the comparison between the analysis of social determinants and drug dependence, it was observed a larger number of research studies highlight the risk factors for consumption, dependence and damages related to psychoactive substances, instead those that investigate the factors that protect or reduce possible damages associated with consumption.Thus, considering the complicated plot which involves the issue of drug use in current times is reduced to the presence of certain determinants, taken as causations among themselves and static realities, it is clear that the predominant perspective found in the studies and the strength of the biomedical paradigm, is historic and natural.The cure focused tradition is stronger than the perspectives that seek to promote health in populations and damage reduction (Spooner, 2009).
Still through this view, there is a predominance of studies focused in microsocial factors and on individuals, in detriment of more complex analysis that approach the drug use as a social and collective issue, showing not only the strength of individualist and essentialist perspective in that field, but also pointing to the nefarious effects of the responsibilities in relation to people that come from that epistemological tradition (Dimenstein et al., 2017).This perspective even turns the individual into a target for the treatment, going against the literature of this field of knowledge, which points to a better effectiveness of actions based in the community and local environment (Ronzani, 2018).
Beyond that, it is important to critically analyze the fact that, when making a comparison between the classification of countries in terms of HDI and the categories of the kind substances, groups and studied social determinations, level of determinations and the kind of outcomes (positive or negative), there were no differences found in the results in these countries, even though they had inequalities in relation to the human development index.Though we know the limitations of HDI as a social development index of a country or region and that this index is not central in our analysis and study aims (Oliveira, 2005), we opted to use it as a first approximation in the comparison.
We suggest that other studies can use more sensitive indexes and analysis for more specific aims in this direction.Even considering these limitations, the data suggest certain homogeneity in the characterization of these studies, highlighting the epistemological emphasis of the publications again.In this regard, we highlight the existence of a great difference not only in terms of the cultural and socioeconomic reality, but also that of epidemiology and pattern of use in different regions, and the different impacts and cross-sections related to the social determinations and psychoactive substance disorders (Galea et al., 2005).This way, the need to think about research production and more comprehensive and contextualized evidence to the characteristics of the different territories.
Thus, it is necessary to consider the relevance of the researches of a qualitative design.Despite being in the minority, the seven studies that used this methodological approach, in a general manner, pointed to the importance of understanding the social determinations in a dynamic, procedural and complex form and led to a deeper consideration of these determinations and substance abuse, particularly among certain social groups.The studies done with women, for instance, understand that the analysis about the drug use among this group tends to take into account the social context they live in, drawing attention to the importance of the articulation between culture, history and social aspects of that community and health care (Badry & Felske, 2013).Therefore, it can be noted that the qualitative works have a tendency to articulate the different factors involved and the many dynamics in psychoactive substance consumption, reinforcing the importance from this perspective which seeks for cultural meaning of practices and the meaning of phenomena such as drug use.
Lastly, it is important to highlight that the results found were possibly influenced by the criteria found by this research.Initially, although it was not the focus of this study to create a conceptual discussion, as we have previously pointed out, the option to keep the term Determinants of Social Health might have in itself created a selection of articles of specific regions, once the term is constant in the descriptors database.Despite that, the specificity and emphasis of the search based on drug addiction, not use patterns, might also have generated more specific results.Still, as an early article in this sense, we opted to keep the search criteria, according to the PRISMA protocol and an analysis more focused on drug addiction.In any case, future and complementary studies about wider use patterns and a more conceptual study about social determinants and determinations shall be held.Despite these methodological choices possibly not finding other researches, we believe that our article has reached its aims and generated relevant information for the area.

CONCLUSION
It is emphasized that, keeping in mind the focus of studies in individual/biological factors related to a curative perspective about the drug use disorders, it becomes necessary to have more works of a comprehensive basis, grounded in history and a wider understanding, which looks beyond the individual and epistemological character found in most of the studies.Therefore, we should highlight the importance of a discussion about drugs from the perspective of social determination whether for a wider understanding of the phenomena, or for the contextualized planning and the strengthening of social policy such as protective actions, which will minimize the consumption in great part of the population, especially in peripheral economic countries.It's important, therefore, to promote and incentivize the production of a larger number of investigations in the area, as well as it is necessary to amplify methodologies, emphasis and theoretical perspectives to make it possible richer and more adequate analysis about the use of psychoactive substances.

Figure 1 .
Figure 1.PRISMA flow-chart.Identification procedures and Studies Included in Systematic Review Selection.

Figure 2 .
Figure 2. Number of articles published by year (N=78)

Table 1
General Data of the Selected Studies (n=78) Note ª Quantitative and Qualitative methodology.;b Except Mexico.

Table 3
Social Determinants that are Risk factors for Substance Use distributed in Macro, Meso and Micro Social levelsMacro, Meso and Micro Social  Levels (N=78)