Introduction

In all societies, those in lower socio-economic positions experience worse physical and mental health (CSDH, 2008). Although health improvements have been seen in many countries, health inequalities mean that those in more disadvantaged positions experience slower improvements, widening the gap between those at the top and those at the bottom. The World Health Organization established the Commission on Social Determinants of Health in 2008 to ‘marshal the evidence on what can be done to promote health equity, and to foster a global movement to achieve it’ (CSDH, 2008: 1), recognising that equity in health and well-being gives an indication of the social development of a society.

As a result of this, the Marmot review was tasked with proposing strategies to reduce health inequalities in England (Marmot et al, 2010), and rightly recognised that health equality requires a debate about what kind of society we want to live in. A child born into a position of lower socio-economic status is more likely to experience problems with health, mental health, nutrition and education, have less stable employment, feel stigmatised, and experience a range of other difficulties (Griggs and Walker, 2008). However, poverty alone is not the most influential factor. When considering societies as a whole, there is a clearer relationship between poor health outcomes and societal inequality, meaning that rich countries with a steep social gradient do worse than poorer, but more equal, countries (Wilkinson and Pickett, 2010). This chapter will consider how addiction is influenced by health inequalities, and will reflect on how the recommendations of the Marmot review could influence recovery from addiction.

Health inequalities are seen across the field of addiction, although this is a field that is poorly defined. The Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM V) has set criteria for substance use disorders, capturing the key, defining feature of addiction: continued use of a substance (or continued pursuit of a behaviour), despite negative consequences. Canadian Professor of Psychology Bruce Alexander (2008: 29) has described addiction as ‘overwhelming involvement with any pursuit whatsoever (including, but not limited to, drugs or alcohol) that is harmful to the addicted person, to society, or to both’.