High and Rising Mortality Rates Among Working-Age Adults (2021) / Chapter Skim
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7 Opioids, Other Drugs, and Alcohol
7 Opioids, Other Drugs, and Alcohol
Pages 219-282
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3 This figure includes intentional drug poisonings (suicides)
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. TRENDS IN MORTALITY DUE TO DRUG POISONING AND ALCOHOL Drug Poisoning Mortality The increase in mortality from drug poisoning over the past three decades has been alarming.
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seminal study of increasing midlife mortality from "drugs, alcohol, and suicide" showed that the death rate among U.S. adults ages 45–54 due to poisoning -- which included prescription and illicit drug poisoning and alcohol-related deaths, both unintentional and of undetermined intentionality -- increased for White adults of all educational levels, as well as for Black and Hispanic adults, between 1999 and 2013.
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(deaths per 100,000 population) from drug poisoning by sex, age, and race and ethnicity.
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of the increasing educational disparity in working-age mortality over the 1990–2015 period was due to drugs, alcohol, or suicide, with educational differences in drug poisoning mortality particularly important for understanding widening educational disparities in working-age mortality among White women and men since 1990. For Black women and men, however, the findings differed.
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Among Hispanic females, rates were lowest in large central metros. In some ways, the drug overdose crisis can be considered a national crisis, as drug poisoning mortality rates increased in every U.S.
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Hispanic Males Age 45-64 30 25 20 15 10 5 0 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro FIGURE 7-2 Drug poisoning mortality rates (deaths per 100,000 population)
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Non-Hispanic Black Females Ages 25-44 40 16 35 14 30 12 25 10 20 8 15 6 10 4 5 2 0 0 1990-1993 2000-2002 2009-2011 2015-2017 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro Small/Medium Metro Nonmetro i. Hispanic Females Ages 25-44 12 10 8 6 4 2 0 1990-1993 2000-2002 2009-2011 2015-2017 Large Central Metro Large Fringe Metro Small/Medium Metro Nonmetro j.
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by region and state, 1990–1992 and 2015–2017. NOTE: Drug poisoning mortality rates are shown for 1990–1992 (blue squares)
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Deaths per 100,000 Population 10 20 30 40 50 60 70 80 90 0 100 Pennsylvania New Hampshire Rhode Island Maine Massachusetts NORTHEAST Northeast FIGURE 7-3 Cointinued Connecticut Vermont New Jersey New York Ohio Michigan Indiana Missouri MIDWEST Wisconsin Illinois Midwest Kansas Minnesota Iowa North Dakota South Dakota Nebraska West Virginia Kentucky 1990-1992 Tennessee District of Columbia Delaware Oklahoma Maryland b. Females ages 25-64 2015-2017 Louisiana North Carolina South Florida South Carolina SOUTH Alabama Arkansas Virginia Georgia Mississippi Texas Utah New Mexico Nevada Wyoming Arizona Alaska Idaho West Colorado Montana Washington WEST Oregon California Hawaii 228
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that involved opioids, by sex, 1999–2018. NOTE: The percentage of all fatal drug poisonings that involved opioids is shown for males (blue squares)
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by sex, 1979–2018. NOTE: The number of fatal drug poisonings involving opioids is shown for working-age males (blue squares)
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Therefore, deaths are counted under each drug that was involved. Deaths were classified as drug poisonings if the underlying cause of death was a drug poisoning ICD-10 code (X40–44, X60–64, X85, and Y10–Y14)
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. Alcohol-Induced Mortality Mortality from alcohol-induced causes followed different trends from those involving drug poisoning, although here, too, working-age Whites experienced larger increases in mortality relative to working-age Blacks or Hispanics (Figure 7-7)
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SOURCE: Data from National Vital Statistics System Detailed Mortality Files, https://www.cdc.gov/nchs/nvss/deaths.htm.
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Rates remained constant throughout most of the period among Hispanic females ages 25–44, only increasing slightly in the most recent period, between 2012–2014 and 2015–2017. These mortality trends are consistent with those identified by Kerr and colleagues (2009)
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The temporal trends observed in alcohol-induced mortality align with temporal trends in per capita alcohol consumption (Kerr et al., 2009, 2013a)
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Deaths per 100,000 Population 10 20 30 40 50 60 0 Maine Rhode Island Vermont Massachusetts Connecticut New Hampshire Northeast NORTHEAST New York New Jersey Pennsylvania South Dakota North Dakota Iowa Nebraska Minnesota Indiana Kansas Midwest Michigan MIDWEST Wisconsin Ohio Illinois Missouri Oklahoma West Virginia 1990-1992 South Carolina District of Columbia Tennessee Florida a. Males ages 25-64 Kentucky 2015-2017 Arkansas Texas South SOUTH North Carolina Louisiana Alabama Delaware Georgia Virginia Mississippi Maryland New Mexico Wyoming Arizona Alaska Oregon Montana WEST West Colorado California Washington Nevada Idaho Utah Hawaii 236
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SOURCE: Data from CDC WONDER Online Database, https://wonder.cdc.gov.
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And although both drug and alcohol-induced mortality rates increased among working-age Whites, younger working-age Whites experienced larger increases in drug poisoning mortality relative to their older counterparts, who experienced larger increases in mortality from alcohol-induced causes. With respect to geography, Western states experienced the smallest increase in drug mortality but the largest increases in alcohol-induced mortality.
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These differences in drug and alcohol-induced mortality trends could be the result of differences in the etiology of mortality from these causes. Unlike drug poisonings, which are often acute and due to overdose, most alcohol-induced deaths are chronic and are the result of many years of steady alcohol consumption.
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Yet these are not competing explanations for the nation's overdose crisis; rather, the increase in the availability of drugs and both the long-term and increasing vulnerability of these population groups combined to create and fuel the rising trend in drug poisoning deaths. The country's drug overdose crisis represents a "perfect storm" of the flooding of the market with highly addictive yet deadly substances and underlying U.S.
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Department of Justice, Drug Enforcement Administration, Automated Reports and Consolidated Ordering System (ARCOS) , https://www.deadiversion.usdoj.gov/arcos/retail_drug_ summary/2013/index.html. Prescription opioid deaths data available from Centers for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, http://wonder.cdc.gov.
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. In 1997, the American Academy of Pain Medicine and American Pain Society issued a joint consensus statement promoting the benefits of using opioids for chronic pain management (Haddox et al., 1997; National Academies of Sciences, Engineering, and Medicine [NASEM]
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In addition to misleading physicians, the FDA, and the public about OxyContin's addiction risk, Purdue used aggressive marketing tactics that were unprecedented for a Schedule II drug.9 From 1996 to 2001, Purdue conducted more than 40 national pain management conferences; recruited and trained physicians for national speaker bureaus; compiled prescriber profiles on individual physicians to target those with already high rates of opioid prescribing; developed a lucrative bonus system for its sales representatives; distributed "patient-starter" coupons that provided patients with free prescriptions for a 7- to 30-day supply of OxyContin; and distributed numerous branded promotional items, such as tools, stuffed plush toys, and compact discs ("Get into the Swing with OxyContin," Van Zee, 2009)
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Some unscrupulous physicians viewed the increased demand for prescription opioids as an entrepreneurial opportunity, which resulted in high-volume-prescribing pain clinics (some of which functioned as "pill mills") across the United States.
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. This improper storage contributes to prescription opioid diversion through theft by relatives, friends, and strangers who enter households to provide services (e.g., repairs, cleaning, home health care)
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In states that monitored physicians' prescribing of opioids and other Schedule II drugs, deaths due to drug poisoning were lower. Alpert and colleagues (2019)
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, lowering its prices and introducing a new clientele to the drug. This new market, combined with the existing heroin client base, ushered in the second wave of the opioid overdose crisis, in which the consolidation of the heroin supply chain in Mexico and the much more widespread availability of heroin in the United States than in the past led to an increase in heroin overdose deaths.
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Undoubtedly, saturation of the market with highly addictive and potent opioid painkillers was an essential spark for the massive increase in fatal drug overdoses over the past three decades. But it does not explain why rates of addiction and overdose are higher among certain population subgroups than others or why rates of overdose from other drugs, including methamphetamine, cocaine, and benzodiazepines, continue to climb.
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per capita alcohol consumption occurred during the mid1970s to mid-1980s and was followed by a decline throughout the late 1980s and early 1990s (Haughwout and Slater, 2018)
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Some of these explanations focus on factors proximate to individuals -- physical pain, mental illness, adverse childhood experiences (ACEs) , and psychological distress or despair -- and others on factors more structural and distal -- macro-level economic and social changes.
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Applying learning theory to addiction has robust clinical implications, such as the potential for teaching strategies for reducing addictive behaviors. Still, the psychological model does not account for the social and environmental context of a person's experience with addiction.
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Indeed, some of the states with the highest levels of religiosity are also those that have experienced the greatest increases in mortality due to drug poisoning and alcohol-induced causes (Norman, 2018)
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. Adoption of Medicaid expansion was associated with a 6 percent lower rate of total opioid overdose deaths compared with the rate in nonexpansion states.
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In a recent study of adults ages 25–74 using data from the mid-1990s and early 2010s, Glei, Stokes, and Weinstein (2020) found that physical pain was linked more closely to the rise in the misuse12 of prescription opioids relative to other drugs.
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Unfortunately, ongoing population surveys and other nationwide surveillance using comprehensive indicators of adult mental illness are 13 See also Chapter 8 for a discussion of the relationship between mental illness and suicide.
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found increases of 37 percent, 94 percent, and 170 percent in diagnoses related to alcohol, drugs, and suicidal ideation/behavior, respectively, from 2009 to 2018. An important report on the frequency of and trends in various mental illnesses was produced for the United States for the period 1990–2016 (U.S. Burden of Disease Collaborators, 2018)
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document strong relationships between ACEs and drug and alcohol misuse, age of initiation, high-risk misuse (e.g., injection drug use) , and nonfatal overdose, all of which are risk factors for fatal drug poisoning and alcohol-related death.
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Examining mortality trends among Whites ages 45–54 without a college degree over the period 1999–2013, Case and Deaton (2015, 2017) show that the main causes of death driving the increase in mortality in this population were drug and alcohol poisoning, suicide, and chronic liver diseases and cirrhosis.
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These same communities are now marked by disconnected families, social disorganization, and high unemployment; hopelessness and despair abound among individuals, families, and the community at large, and many youth see no future. The next section elaborates on the role of these structural changes in mortality trends.
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was significantly associated with drug use among adults. In a national study of college students, self-reported feelings of hopelessness, sadness, and depression were associated with significantly greater odds of nonmedical prescription opioid use (Zullig and Divin, 2012)
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They concluded that trends of worsening psychological health are a broad-based phenomenon. In commenting on this analysis, Cherlin (2018)
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Although the study design was not causal, they conclude that the rise in mortality in these nonurban areas was caused primarily by harmful coping behaviors related to underlying social and economic factors in these communities, consistent with the despair hypothesis of Case and Deaton. As noted earlier in this chapter, drug poisoning mortality rates have risen in metro and nonmetro areas alike and across all racial/ethnic groups (to varying degrees)
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show, nearly all of the increase in drug poisoning over the prior three decades was among those without a 4-year college degree. While the rates increased slightly among those with a bachelor's degree, these increases
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They found that drug overdoses, but not suicides or alcohol-related deaths, contributed substantially to growing educational inequities in life expectancy among White males and, to a lesser extent, White females. As a result, they caution against combining drug, alcohol, and suicide deaths into a composite despair-related category and suggest that the popularization of the despair hypothesis threatens to divert attention from ongoing racial/ ethnic health inequities, as well as from other causes of death that have contributed to widening educational disparities, including cardiovascular diseases, cancers, and other internal causes.
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, have had differential effects on population subgroups and geographic areas. These trends may explain in part the geographic patterns in drug poisoning mortality discussed in Chapter 4, as well as those affecting other health outcomes discussed later in this report.
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The end result has been to intensify the disproportionate geographic clustering of multigenerational economic distress in many parts of the United States. The geographic distribution of economic decline, the loss of manufacturing and mining jobs, the decline in wages for blue collar workers, and the rise in poverty in some communities all correspond to the recent surge in drug deaths (Iceland and Hernandez, 2017; Saez and Zucman, 2016; Thiede, Kim, and Valasik, 2018)
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Shifting a county from the 25th to the 75th percentile of exposure to PNTR was associated with an increase in the drug poisoning rate of 2 to 3 deaths per 100,000 population each year after the policy was instituted, a significant share of the average mortality from drug overdoses during the period 1999–2013. This increase in drug-related mortality was observed across a large portion of the working-age population (most age groups between 20 and 54)
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examined drug overdose rates for specific opioids in 2002–2004, 2008–2012, and 2014–2016. They identified three distinct opioid epidemics (prescription opioids, heroin, and prescription–synthetic opioid mixtures)
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. Using data from the High School and Beyond study for 11,680 males who were in high school during the 1980s and 2015 mortality data from the National Death Index and the Social Security Death Index, the authors found higher rates of suicide and drug poisoning among men who had planned to work in occupations that declined during the 1980s and 1990s.
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Alcoholinduced deaths also increased among Whites during the entire study period, and while alcohol-induced deaths declined among Blacks and Hispanics throughout the 1990s and early 2000s, those declines leveled off during the late 2000s and shifted to increases in the 2010s. The rise in drug poisoning deaths has been well studied, and that research has yielded some plausible explanations for this phenomenon.
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, and physicians (encouraged by pain management advocates and pharmaceutical companies) , combined with weak government regulations, sparked a massive increase in opioid prescribing and the subsequent rise in prescription opioid misuse, addiction, and overdose.
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, and nonfatal overdose, all of which are risk factors for fatal drug poisoning and alcohol-related death. Research on temporal trends in the prevalence of ACEs is sparse, however, making it is difficult to determine whether changes in the prevalence of these experiences are related to the changes observed in working-age drugand alcohol-related mortality rates.
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This economic decline has occurred concomitantly with declining marriage rates, increases in single-parent families, declining social safety nets, and increased disconnection from social institutions. Ultimately, there is strong observational evidence that the contexts of everyday lives and the decline in opportunities for adults without a college degree contributed to the rise in drug poisoning and alcohol-related deaths.
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addiction and overdose crisis and prevent future crises. In general, the most effective interventions target both risk and protective factors at multiple levels, including the individual, family, community, and society.
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. People with SUDs face numerous barriers to accessing the treatment they need, including limits on health insurance coverage, low Medicaid provider participation rates, shortages of mental health and substance use specialists, and fragmentation in care delivery ("carve-outs" and other policies that separate mental health from physical health care)
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. RECOMMENDATION 7-2: Federal agencies, in partnership with pri vate foundations and other funding entities, should support research on the effectiveness of behavioral health interventions in reducing mental illness and its consequences; on improved methods for delivering men tal health and substance use treatment, harm reduction products and services (e.g., naloxone, medication-assisted therapies, needle exchange programs, safe injection sites)
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contributed in important ways to the increase in drug poisoning mortality rates (regardless of whether SUDs themselves have actually increased)
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RECOMMENDATION 7-3: The National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Cen ters for Disease Control and Prevention, the Food and Drug Adminis tration, and other relevant federal agencies should support research to address the gaps in knowledge regarding the underlying causes of the rise in drug poisoning, alcohol-related death, and suicide. Specifically, this research should be focused on • the mechanisms underlying physicians' and patients' unintended responses to tighter regulation of drugs with a high risk of misuse and addiction, such as cases in which individuals dependent on pre scription opioids were pushed to markets for heroin and fentanyl,
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, the interrelationship between mental and physical health and the implications for mortality trends also require further exploration, as some physical health morbidities (e.g., obesity, diabetes, hypertension) that have contributed to rising midlife mortality rates may also be related to mental health and/or psychological distress.
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. Improvement in these data would enable better testing of hypotheses as to why drug mortality rates have increased among individuals without a 4-year college degree but remained relatively flat among those with a college degree (Case and Deaton, 2020)
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Nevertheless, there are important gaps in the availability of information on adult mental illness rates in the United States as a whole and in regional jurisdictions. More of this information is needed to understand trends in the relationship between mental health conditions and SUDs; identify the levels of unmet population need for prevention and treatment of these conditions; and assess the outcomes of these conditions, including social dysfunction, drug and alcohol use, and suicide and other related mortality.
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, as well as to other relevant national health surveys, such as the National Health Interview Survey and the National Survey on Drug Use and Health. To advance understanding of the mechanisms and control of these experiences, this information should be improved by facilitating maximal record linkage of cohort findings to available social, military, medical, psychiatric, environmental, and law enforce ment records.
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