The Substance of Attachment: Insights on Rural Opioid Use

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Mental health practitioner Alison Mitchell explores the opioid abuse problem, particularly related to its impact on relationships and rural communities.

The United States has an opioid abuse problem. Though the issue is widely recognized, addressing it remains challenging, particularly in rural areas. The often-confusing array of behaviors and decisions individuals may make when influenced by drugs can be overwhelming, indeed even alarming. One way to make sense of it all is to think of the drug as playing the role of a substitute for human relationships.

Humans seek connections with others. We form lasting bonds–attachments–with others who can provide support and comfort. Secure attachment can support health and well-being throughout life. When attachment relationships are disrupted or unpredictable, distress results. In the face of chronic and/or severe relational disruptions, drugs can appear to provide a solution. They can ease the pain of relational “wanting” and seem to provide comfort and security through a perceived release from what may be experienced as the challenges of reality. From an interpersonal perspective, the substance of choice seems to fill a relational void that existed in the past and persists in the present.

Opioids–drugs like heroin, fentanyl, narcotic pain medications–are particularly effective in filling this kind of relationship “gap” because of how they interact in our brains. Opioids act on opioid receptors in the brain and contribute to the increased release of dopamine, the “feel good” chemical in the brain, in specific areas. They can make us feel sensations of pleasure, motivation, calm, relief from pain, euphoria, and drowsiness or sedation.

Unfortunately, like any substance, opioids can be misused, creating “highs and lows.” The high is a chemically induced state of safety and comfort that mimics what a child might experience in the presence of a reliable, attuned caregiver. However, drug use disrupts human relationships, at once strengthening the desire for real connection and reinforcing the power of the opioid high. From the perspective that any relationship is better than no relationship at all, in a situation in which human relationships have failed, a relationship with a drug becomes an attractive alternative.

Just as we seek comfort and care from other individuals, we also seek comfort and care through access to services in our communities. Rurality, the condition of living in a remote, sparsely populated location, can hamper a person’s ability to maintain community connections, which can make opioids more problematic for some individuals in rural areas.

Though rural populations are diverse, there are some commonalities, such as less access to resources and services compared to urban areas; the need to travel great distances to receive services; geographic isolation; and lack of public transportation options. In addition, conditions like lack of high speed internet or even harsh weather conditions can cause further isolation, disrupting relationships with community systems. For a rural individual already struggling with opioid addiction, their drug use may take on many layers of potential meaning and importance, from filling an individual relational gap to providing escape from isolating, potentially harsh living conditions.

Over time, as substance dependence grows, the body comes to rely physically on the presence of the chemicals, and what was once an attractive coping mechanism becomes a physical necessity. The threshold for physical dependence is different for every individual, but the end result is the same. With opioid use, over time, the brain becomes reliant on the presence of the drug. When that drug is not present, the brain sends signals that it needs more, often described as cravings. If unfulfilled, the body begins to go into withdrawal. Withdrawal symptoms are just as unique as the individual, but in general, the physical symptoms of opioid withdrawal are often described as the worst case of the flu imaginable. In addition, opioid withdrawal often carries with it emotional and psychological aspects that can include intense feelings of emotional pain, aloneness, and desperation. To avoid the experience, dependent users seek more drugs, and the cycle continues.

How can we address this vexing issue? Medication-assisted treatments (MATs), such as opioid replacement therapy or opioid blockers, paired with individual mental health therapy and/or family therapy that attends to treatment relationships are widely utilized and successful because they address both the physical and the psychological impacts of addiction. When access to health care is a challenge, which can be the case in rural or underserved areas, medications that can be administered on a monthly basis might be more effective for some patients.

The therapeutic relationship can be both a model of healthy, adaptive interpersonal interactions and also a safe place in which to gain insight into and work through past challenges. This includes consideration of the role of the drug as a substitute relationship and attachment object when human connection proved too damaging or unpredictable. Through healthy interpersonal interactions in therapy while supported by harm-reducing opioid replacements, individuals with opioid use disorders can address both their physical dependence and underlying attachment-based challenges.

Humans desire connection. When bonds are severed or disrupted, interpersonally and/or due to where people live, people naturally seek to fill the void through other means, sometimes involving drug use. Some rural areas are underserved and lack resources, compounding the opioid problem for some people in those areas, but the reasons for the lack of resources are complex. Opioids, by the nature of their “high,” temporarily relieve negative feelings associated with isolation and disconnection. They provide an illusion of security, well-being, and comfort. As such, they simulate human attachments, albeit flawed ones, and contribute to enduringly painful and difficult-to-alter patterns of behavior. Looked at through this lens, once perplexing addiction-driven actions begin to make sense as attempts to create and maintain relationship substitutes.

Alison Mitchell, MAIS, LCSW, is a PhD candidate at the Smith College School for Social Work, adjunct faculty at the University of Maine School of Social Work, and a mental health practitioner in central Maine. Her research focuses on supporting substance-exposed children and families, particularly those with opioid exposure. Ms. Mitchell combines practical experience with research expertise, measuring the impact of service provision for clients and staff alike, using findings to guide future programming or undertakings for agencies and research partners. She serves as a Court Appointed Special Advocates for children (CASA) volunteer guardian ad litem for children in protection cases, and was formerly a K-12 educator and administrator.

This article originally appeared on the blog of the Austin Riggs Center, a therapeutic community, open psychiatric hospital, and center for education and research, promoting resilience and self-direction in adults (18+) with complex psychiatric problems.

The research and sources upon which this article is based can be found at:

Mitchell, A. (2019). Attached, addicted, & adrift: Understanding the rural opioid crisis. Families in Society: The Journal of Contemporary Social Services 100(1), pp. 80-92.