The Role of a Bachelor’s Degree In the Relationship between Poverty, Psychological Distress, and Opioid Misuse: A Moderated Mediation Analysis

Background: Building upon the “deaths of despair” framework, which conceptualizes poverty as a form of structural disadvantage that engenders despair through economic and social decline—contributing to rising mortality from drugs, alcohol, and suicide among working-age adults in the United States without a bachelor’s degree—this study examines the role of bachelor’s degree in the relationship between poverty, psychological distress (proxy for despair), and opioid misuse. Understanding these dynamics is essential for informing policies aimed at mitigating poverty-related health disparities.

Methods: A moderated mediation model was estimated using structural equation modeling framework with data from the 2024 National Survey on Drug Use and Health (N=33,163). The model tested whether having a bachelor’s degree or higher (yes/no) moderates the direct and indirect effects of federal poverty levels (High:≤100%, Medium:100–200%, Low:≥200% [reference]) on opioid misuse (yes/no), mediated by latent psychological distress (Kessler-6 scale). Moderation of the indirect effect was assessed via the poverty-distress path. Analyses used Mplus with WLSMV estimator and results reported as probit estimates.

Results: 41% had ≥bachelor’s degree, 44% male; ages:35–49 (39%), 26–34 (29%), 50–64 (16%), ≥65 (16%). Total effects were significant and similar across educational groups in the high-poverty category (<bachelor’s=0.397,CI=0.328,0.482; ≥bachelor’s=0.364,CI=0.089,0.535). In the medium-poverty category, effects were smaller among those without a bachelor’s degree but substantially larger among those with a bachelor’s degree (0.202,CI=0.126,0.278 vs. 0.462,CI=0.275,0.602). Indirect effects were significant; in the high-poverty group, they were more than twice as large among those without a bachelor’s degree compared to degree holders (0.065,CI=0.053,0.080 vs. 0.029,CI=0.010,0.051), whereas in the medium-poverty group, they were slightly higher among those with a bachelor’s degree or higher (0.039,CI=0.024,0.054 vs. 0.029,CI=0.019,0.038). Direct effects were significant and similar across educational groups in the high-poverty category (<bachelor’s=0.332,CI=0.262,0.411; ≥bachelor’s=0.335,CI=0.060,0.502), but higher among those with a bachelor’s degree or higher in the medium-poverty category (0.422,CI=0.236,0.561 vs. 0.173,CI=0.101,0.255). Moderated mediation was supported: in the high-poverty group, a bachelor’s degree weakened the poverty–distress link (−0.122,CI=−0.194,−0.044) but was not statistically significant in the medium-poverty group (0.036,CI=−0.023,0.091). Conversely, a bachelor’s degree was not statistically significant in the high-poverty group (0.003,CI=−0.259,0.188) but strengthened the poverty–misuse link in the medium-poverty group (0.249,CI=0.045,0.411). Model fit was excellent (RMSEA=0.037,CFI=0.963,TLI=0.947,SRMR=0.026).

Conclusion: In high-poverty settings, a bachelor’s degree attenuates the association between poverty and psychological distress, buffering the indirect pathway; this effect is absent in medium-poverty settings. In moderate poverty, a bachelor’s degree amplifies the direct association between poverty and opioid misuse, with total effects more than double among degree holders. This pattern suggests that non-distress mechanisms—such as relative deprivation, declining mobility, underemployment, and unmet expectations—may drive risk, reflecting a mismatch between education and economic opportunity. Overall, the results show that education is not uniformly protective and may increase risk under moderate poverty. Separate policy approaches are needed. Expanding access to higher education may mitigate distress-related risks among individuals in high-poverty settings. For bachelor’s degree–educated individuals in moderate poverty, policies should target non-distress mechanisms by promoting upward mobility, reducing underemployment, and strengthening the economic returns on bachelor’s degree.