Steps toward a theory of place effects on drug use: Risk, marginality, and opportunity in small and remote California towns.

The risk environment concept provides a framework for documenting ecological influences on drug use, and a platform to engage with social theory to identify mechanisms behind place-based health disparities. Health scientists conceptualize these mechanisms in terms of social determinants of health, social scientists in terms of syndemics and structural violence. I supplement these perspectives with Pierre Bourdieu's concepts of social space, practice, and habitus to offer a broader analysis of how place shapes drug-related health risks, particularly outside of the large cities where most research is conducted. This approach encompasses inequality, conflict, and social change at multiple levels of social organization, from macrodistributions of power to trajectories of individual drug use. I offer three pointers for scholarship on drug use in nonurban places, which I illustrate with findings from an ethnographic study of opioid use and opioid-related services in California. First, replace the folk notion of "rural" with geographic categories grounded in relevant social structures and institutions, such as social networks or illicit drug markets. Second, examine how variation in the structure of social and physical space affects processes of marginalization and criminalization. Third, avoid negative definitions of nonurban places, and instead explore their distinctive institutions and opportunity structures. Following this approach, I define acquainted marginality and small-town habitus to explain how dense networks and geographic isolation shape local government and survival strategies among people who use drugs. I find that in small and remote towns, personal and professional relationships overlap in ways that augment surveillance and stigma, but can also facilitate leniency and progressive policy change. I conclude by using these findings to outline a theory of place effects on drug use and addiction to encourage future research in these directions.