The Silent Death

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A couple months ago I wrote about a controversial study which reported the rising mortality rates among middle aged whites – a trend which broke the model of ever-decreasing mortality rates across racial groups in the United States and all wealthy industrialized countries worldwide. I argued that, whether it was principally cause or effect, it was critical to understanding contemporary US politics. The leading driver of this rising mortality was drug overdose, chronic substance abuse (liver disease, etc.) and suicide. Subsequent critiques of the study appeared to show the trend was somewhat exaggerated in the original study and more concentrated among white women. Still, the overall findings held up.

Since then I’ve been reading more about the rising rates of drug overdoses themselves. The numbers are truly stunning. The number of people now dying from drug overdose is comparable to the number dying annually from AIDS during the peak of the AIDS epidemic in the mid-90s. Now, this isn’t a perfect analog, certainly. Drug overdose goes back either centuries or millennia depending on how you want to define it. AIDS was a totally new disease in the US starting in the early 1980s. But it does provide a sense of scale.

50,000 American died of AIDS in the peak year of 1995. In 2014, just over 47,000 people of overdose.

Another way to put this in perspective is to consider the rate of overdose deaths per 100,000 people per year. Most articles on this subject look at the rise of overdose deaths since the turn of the century. As you can see in this chart, the rate more than doubles (137%) between 2000 and 2014 …

But the trend is even more striking when you go back further. This chart takes the story back to 1970 up through 2006 …

In other words, the year 2000 wasn’t really a baseline but just one point in what was already a dramatic rise.Now, there’s an important caveat I want to add here. The more recent chart is age adjusted, which is to say that it controls for the shifting distribution of ages in the population over time. (A greater percentage of Americans are middle aged or elderly today than was the case 50 years ago for instance.) I think the later chart may not be. If that is the case, some of the earlier run-up may be due to the aging of the population.

Still, as you can see, in 1970, in what many think of as the heyday of the drug culture, overdose was rare – little over 1 per 100,000 Americans per year. Today it’s 15 per 100,000. As CDC epidemiologist Dr. Leonard J. Paulozzi put it in 2010, “In the 1970s and 1980s, the annual rate was less than 2 deaths per 100,000 people per year. However, starting in 1990, the rates began to increase dramatically so that now we are approaching 9 or 10 deaths per 100,000 people per year in the United States.”

Finally, race. The number are heavily driven by race. The overdose mortality rate for whites was 19 per 100,000 in 2014, 14.7 for African Americans and 6.7 per 100,000 for Hispanics. As you can see from this chart just released by the CDC, not only is the rate for whites higher in absolute terms, the run-up in the numbers are strongly driven by the rise among whites. Moreover, among whites the numbers are concentrated in rural and semi-rural areas and among people at the bottom of the income scale.

Now, it may go without saying but it’s worth saying: I don’t think there’s any question that this issue is starting to rise to the surface in significant part because it’s affecting white people. But that doesn’t make the numbers any less real.

So what’s happening? Some basic points are very clear. The rise is driven by prescription drugs (Benzodiazepines and opioid pain killers) and heroin deaths. Some of the trend starts with changing attitudes toward pain and a growing consensus within the medical community a generation ago – in itself salutary – that people should not have to live with chronic pain. In part because of that the amount of legally prescribed pain killers (mainly opioids) has grown by over 400% since 1999.

There’s some anecdotal evidence that a significant amount of this comes from workplace injuries, concentrated among lower income/blue collar workers who do manual labor. This is probably one reason why West Virginia is one of the worst affected states – in addition to the fact that along with Texas its one of the hardest states to find treatment in. Still, pain hasn’t gone up 400% in the last twenty years. There is probably a significant role for more pain being treated which previously went untreated or suffered in silence. But there’s little doubt that a big part of the equation is massive over-prescription of drugs and very limited access to drug treatment. As I said, efforts to crack down have had the perverse affect in many cases of driving people to heroin. With heroin a substantial number of the deaths come from heroin which is either laced with or diluted with a much deadlier drug called fentanyl. Sometimes dealers sell pure fentanyl as heroin.

One ironic and tragic trend appears to be that as authorities have tried to crack down on prescription drug abuse and illicit trafficking, it’s driven addicts to using heroin. Listen to this number. As recently as 2010, there were just over 3000 heroin overdoes in the United States. In 2014, that number had jumped to 10,574.

As I’ve said, the numbers are simply stunning and the effect is highly concentrated demographically and geographically. I’m going to follow up with some more discussion, theories of why this is happening, its effect on society at large, how it’s starting to bleed into the political realm (New Hampshire is one of the top affected states). But for now, I just wanted to lay out some of the numbers. Because as much as we’ve probably all heard about the rise of prescription drug abuse on the nightly news here and there, the numbers are astounding.

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