Marginalization, Addiction, and Chronic Disease: Understanding Determinants and Intersections in Population Health

Introduction

Marginalized populations, including those experiencing homelessness, incarceration, veteran status, racial and ethnic minority identity, or poverty, face disproportionate burdens of chronic disease, substance use disorders (SUDs), and mental illness. The complex interplay between social determinants of health, structural inequities, and trauma magnifies vulnerability in these communities. For nurses in graduate and advanced practice roles, understanding these socio-cultural dimensions is critical for shaping equitable and effective public health interventions.

Determinants of Risk in Marginalized Populations

The risk of developing chronic disease, substance use disorders, and mental illness in marginalized populations is shaped by social, economic, and environmental determinants.

Research consistently shows that poverty, discrimination, trauma, and lack of access to care intersect to create cycles of vulnerability. Heerde et al. (2023) conducted a longitudinal study of young adults in Australia and the United States and found that justice system involvement, financial insecurity, and adverse childhood experiences (ACEs) predicted higher rates of chronic illness, mental health problems, and substance use. Similarly, Dhinsa et al. (2023) identified that individuals from racial and ethnic minorities, sexual minorities, and uninsured populations were significantly less likely to access mental health or SUD treatment, even when in need of care.

These findings illustrate that systemic marginalization, such as racism, homophobia, and class inequality, translates directly into poor health outcomes. At a population level, Valenzuela et al. (2024) demonstrated that community-level social deprivation correlates strongly with multimorbidity among patients in community health centers, reinforcing how neighborhood disadvantage perpetuates health inequities.

From a biological standpoint, the National Institute on Drug Abuse (2024a, 2024b) emphasizes that comorbidities among people with SUDs are common, particularly with depression, anxiety, and cardiovascular or metabolic disorders. Structural and physiological stressors combine, leading to what public health scholars describe as a syndemic, the intersection of multiple epidemics within contexts of social inequity.

Intersections Among Veterans, Homeless, and Incarcerated Populations

Veterans, people experiencing homelessness, and incarcerated individuals often represent overlapping populations. Veterans disproportionately experience homelessness and are also more likely to have a history of incarceration compared to the general population (Kim et al., 2019). These compounded experiences significantly increase their risk of substance use, overdose, and untreated mental illness.

Tsai et al. (2025) found that homeless veterans had a dramatically higher rate of overdose mortality, approximately ten times that of housed veterans, even after adjusting for other factors. Veterans reentering society after incarceration similarly exhibit higher rates of emergency department visits, SUD-related hospitalizations, and relapse (Kim et al., 2019). These findings underscore that social instability, trauma, and disrupted care continuity exacerbate vulnerability across these intersecting groups.

For nurses and other health professionals, these intersections highlight the necessity of integrated, trauma-informed, and coordinated systems of care that span correctional, community, and Veterans Affairs (VA) systems. Without continuity and holistic support, individuals remain trapped in cycles of instability and poor health outcomes.

Lived Experience: Insights from Soft White Underbelly

In the Soft White Underbelly interview “Matthew, Functional Heroin Addict,” the subject describes maintaining employment while managing a long-term heroin addiction. His story offers a poignant lens into the hidden lives of people experiencing addiction, balancing external functionality with deep internal struggle.

Matthew’s narrative of early exposure to trauma, unstable housing, and emotional isolation reflects how addiction is rarely a matter of choice, but rather a coping mechanism against structural and emotional adversity. As nurses, viewing such stories through a socio-cultural lens cultivates empathy and nonjudgmental practice, reminding us that clinical care must address not only biological symptoms but also social context, dignity, and human connection.

Recent Research: The Changing Illicit Drug Supply and Marginalized Populations

Saloner et al. (2024) conducted a qualitative study exploring the experiences of racial and ethnic minoritized people across three U.S. states as they navigated an increasingly unpredictable illicit drug supply. Participants reported heightened anxiety, overdose risk, and a sense of powerlessness due to fentanyl contamination and unstable market conditions. Importantly, these individuals faced structural vulnerabilities such as policing, racial profiling, and lack of access to harm reduction tools.

This study highlights how structural determinants, not just individual behaviors, shape health outcomes. For marginalized people who already face barriers to care, the shifting drug landscape compounds risk. Saloner et al. (2024) advocate for community-based harm reduction strategies, such as expanded naloxone access, safe-supply initiatives, and culturally responsive outreach, approaches that nurses are uniquely positioned to implement in public health and community settings.

Addressing Health Disparities: Nursing and Population Health Action

Reducing health disparities among marginalized populations requires a multi-level nursing response integrating advocacy, policy, and clinical care.

1. Adopt trauma-informed and structural-competency frameworks. Nurses must recognize how structural factors, racism, incarceration, housing instability, and poverty, affect behavior and health. Routine screening for trauma and social needs should be as essential as clinical assessments. 
2. Implement integrated, wraparound care models. Coordinated systems across correctional, community, and VA services, as described by Kim et al. (2019), can bridge treatment gaps and improve reentry outcomes for veterans and formerly incarcerated persons.
3. Expand harm reduction and housing-first initiatives. Evidence from Tsai et al. (2025) shows that housing instability correlates with overdose mortality. Integrating harm reduction within housing and veteran programs can reduce mortality and enhance recovery.
4. Advance policy and advocacy. Nurses can advocate for equitable healthcare policies that decriminalize substance use, fund supportive housing, and expand access to medication-assisted treatment and mental health services. 
5. Enhance education and workforce preparation. Nursing curricula should include structural competency, cultural humility, and population health strategies focused on marginalized and high-risk populations.

Conclusion

The convergence of social marginalization, chronic disease, and substance use represents one of the most pressing challenges in population health today. Through the lens of lived experience, empirical evidence, and public health frameworks, it becomes clear that improving outcomes requires systems-level interventions, not merely clinical treatment.

Nurses, as advocates and community leaders, are positioned to drive transformation through trauma-informed practice, intersectoral collaboration, and policy engagement. In the words of the Soft White Underbelly interviewee, those living with addiction often “just want to be seen.” Nursing’s commitment to holistic, human-centered care ensures that they are.

References

Dhinsa, J., Roman-Urrestarazu, A., van Kessel, R., & Humphreys, K. (2023). Understanding predictors of mental health and substance use treatment utilization among US adults: A repeated cross-sectional study. Global Epidemiology, 5, 100109. https://doi.org/10.1016/j.gloepi.2023.100109

 

Heerde, J. A., Merrin, G. J., Le, V. T., Toumbourou, J. W., & Bailey, J. A. (2023). Health of young adults experiencing social marginalization and vulnerability: A cross-national longitudinal study.

International Journal of Environmental Research and Public Health, 20(3), 1711.

https://doi.org/10.3390/ijerph20031711

 

Kim, B., Bolton, R. E., Hyde, J., Fincke, B. G., Drainoni, M. L., Petrakis, B. A., Simmons, M. M., & McInnes, D. K. (2019). Coordinating across correctional, community, and VA systems: Applying the Collaborative Chronic Care Model to post-incarceration healthcare and reentry support for veterans with mental health and substance use disorders. Health & Justice, 7(1), 18. https://doi.org/10.1186/s40352-019-0099-4

 

National Institute on Drug Abuse. (2024). Common comorbidities with substance use disorders.

National Institutes of Health, U.S. Department of Health and Human Services.

https://www.ncbi.nlm.nih.gov/books/NBK571451/

 

National Institute on Drug Abuse. (2024). Co-occurring disorders and health conditions. National Institutes of Health, U.S. Department of Health and Human Services. https://nida.nih.gov/research-topics/co-occurring-disorders-health-conditions

Saloner, B., Sugarman, O. K., Byrne, L., Harris, S., Reid, M. C., Shah, H., Hulsey, E., Hurst, A., Kerins, L., King, D., Sherman, S., Kaner, E., Heller, D., & Bandara, S. (2024). Experiences of the changing illicit drug supply among racial and ethnic minoritized people in three US states: A qualitative study.

Harm Reduction Journal, 21(1), 205.https://doi.org/10.1186/s12954-024-01126-3

 

Tsai, J., Szymkowiak, D., & Beydoun, H. A. (2025). Drug overdose deaths among homeless veterans in the United States Department of Veterans Affairs healthcare system. Addiction (Abingdon, England),

120(2), 306–315.https://doi.org/10.1111/add.16689

 

Valenzuela, S., Peak, K. D., Huguet, N., Marino, M., Schmidt, T. D., Voss, R., Quiñones, A. R., & Nagel, C. (2024). Social deprivation and multimorbidity among community-based health center patients in the United States. Preventing Chronic Disease, 21, E75. https://doi.org/10.5888/pcd21.240060