Examining Racial Differences In the Relationship between Poverty, Psychological Distress, and Opioid Misuse: A Moderated Mediation Analysis

Background: Poverty is a well-recognized determinant of opioid misuse, but the mechanisms linking it to misuse may vary across racial and ethnic groups. Psychological distress is a key pathway connecting poverty to opioid misuse, yet prior research has not adequately examined racial and ethnic heterogeneity in both direct and indirect pathways. Addressing this gap is essential for identifying disparities and informing targeted interventions and policies to reduce racial disparities in opioid misuse.

Methods: Data from the 2024 National Survey on Drug Use and Health (N = 58,633) were analyzed using a moderated mediation model within a structural equation modeling framework. Race/ethnicity (Non-Hispanic [NH] White [reference], NH Black, NH Asian, NH American Indian and Alaska Native/Native Hawaiian and Other Pacific Islander [AIAN/NHOPI], NH Multiracial, Hispanic) moderated the direct and indirect effects of federal poverty level (High:≤100%, Medium:100–200%, Low:≥200% [reference]) on opioid misuse, with psychological distress (Kessler-6) as the mediator. Moderation of the indirect effect was assessed via the poverty–distress path. Analyses used Mplus with the WLSMV estimator, and results were reported as probit coefficients.

Results: 46% were male; race/ethnicity: NH White (55%), NH Black (12.5%), NH Asian (4.5%), NH Multiracial (5%), NH AIAN/NHOPI (2%), and Hispanic (21%). Total effects varied across racial/ethnic groups and were nearly double among NH Whites in high vs. medium poverty (0.505, CI:0.470,0.540 vs. 0.273, CI:0.230,0.316). Indirect effects were significant across groups but strongest among NH Whites in both high (0.095, CI:0.081,0.109) and medium (0.060, CI:0.050,0.070) poverty. Direct effects were significant among NH Black in high poverty (0.177, CI:0.043,0.311) and Hispanics in high (0.171, CI:0.065,0.277) and medium poverty (0.142, CI:0.023,0.259), but were smaller than NH Whites, whose effects were nearly double in high vs. medium poverty (0.410, CI:0.338,0.482 vs. 0.213, CI:0.142,0.284). Moderated mediation was supported, with most groups showing negative estimates in high poverty, indicating weaker poverty–distress associations than NH Whites; however, effects were strongest and significant among NH Blacks and Hispanics in both high (−0.254, CI:−0.317,−0.191; −0.336, CI:−0.402,−0.270) and medium (−0.189, CI:−0.249,−0.129; −0.229, CI:−0.273,−0.174) poverty groups.

Conclusion: Poverty was associated with opioid misuse both directly and indirectly through psychological distress, with stronger effects at higher levels of poverty, suggesting that higher income may be protective across racial groups. However, the poverty–distress relationship was weaker among non-Whites compared to NH Whites, particularly among NH Black and Hispanic, indicating that psychological distress may not be the primary mechanism linking poverty to opioid misuse in these populations. Among White, historically advantaged positions may heighten sensitivity to economic hardship, contributing to perceived declines in social status, unmet expectations, and relative deprivation, which may increase psychological distress. In contrast, among non-Whites, greater exposure to structural disadvantage may be associated with lower life expectations, resilience, and stronger social support, weakening the poverty–distress link. Additionally, systemic barriers—such as unequal access to healthcare and substance use treatment and neighborhood disadvantage—may play a more prominent role in linking poverty to opioid misuse in these groups. Future research should examine these potential mechanisms contributing to group differences.