Black life expectancy figures are converging with those of whites—but that’s not a good thing.
Middle-aged whites are getting sicker, dying quicker, and reporting worse mental health. That is what Dr. Anne Case and Dr. Angus Deaton’s groundbreaking 2015 paper on American midlife whites’ rising morbidity and mortality found.
Dr. Deaton told the New York Times that this phenomenon had just one parallel. “Only H.I.V./AIDS in contemporary times has done anything like this,” he said.
This rise coincides with the surge in heroin use, and follows greater leniency in the medical establishment’s views on pain management. In some regions, drug overdoses have accelerated at such a dramatic rate that they have depleted state funding for indigent burials.
Although there is consensus among healthcare professionals that dealing with chronic pain requires more than just a pill, a pill is often the most cost-effective option. Dr. Keith Wailoo, a Princeton historian whose research focuses on the political and economic history of pain, said to NPR’s Freakonomics team:
“There was a general recognition that you needed more than just drugs to deal with people in chronic pain. You needed social workers, you needed surgeons, you needed psychologists, you needed a wide range of others as well as people with pharmacological expertise.
. . . And so, you know one of the economic trends, since the 1980s, with the rise of cost containment, is to sort of see drugs as the cheapest and the fastest solution to our problem.
. . . We are a consumer society that believes in the power of the magic pill.”
Why have epidemiologists, health economists, and other public health experts missed this trend until recently? Aggregated data on mortality rates in the United States show a persistent, long-term decline. However, once disaggregated by age and race, whites aged 45-54 show a higher mortality rate than US Hispanics, and the citizens of six other rich nations.
A look into the changes in midlife mortality rates from 1999 to 2013 reveals something awry. The numbers are remarkable.
The data show that whites exceed blacks and hispanics in increases in mortality due to poisoning, intentional self-harm, transport accidents, and chronic liver cirrhosis—all categories including all-cause mortality. Over the 15 year period, all-cause mortality has increased by more than 33 per 100,000 for whites, but decreased by 214 and 63 per 100,000 (poht) for blacks and hispanics respectively.
Whites with a high school degree or less are the cross-section in greatest peril, the data reveal. This group experienced an over 134 poht increase in aggregate mortality and leads in all mortality subtypes. This group also reports major declines in mental health, an increase in financial stress, and increases in dangerous self-medicating behavior like alcohol and drug abuse.
Most notable is the over 44 per 100,000 increase in drug or alcohol poisoning related deaths.
In 2014, the Journal of American Medical Association Psychiatry published a study on heroin users demographics confirming that newer heroin initiates are more likely to be white, older, live in non-suburban areas, and have previously abused prescription painkillers. The CDC now recognizes the surge in prescription opioids sold in the U.S—a figure that has quadrupled since 1999—as a driving force in the 15-year increase in opioid deaths and deems opioid abuse a “serious public health issue.”
The Economist graph to the left illustrates the substitutability of prescription opioids, and heroin and synthetic opioids.
Around 2010, doctors and healthcare providers began to notice that, for many states, the most prescribed drugs were these opioid painkillers–and they were being prescribed at higher rates than ever before. Over the past few years, pharmaceutical companies, doctors, and local communities have rolled out supply-side measures to subdue addiction, limit patient access, and reduce fatalities. The dip in the supply of prescription opioids and heroin’s low initial cost pushed consumers to heroin, once addicted to prescription meds. An estimated 4 out of 5 new heroin users had previously been addicted to prescription pain meds.
In policy advocacy, the low-hanging fruit—the low marginal cost effort—is the elusive pick. But, giving doctors sensible guidelines regarding the quantity and strength of pain pills to prescribe might just be that low-hanging fruit. Given the mixed results from rehabilitation programs and anti-drug educational efforts, further supply side efforts seem reasonable.
The trick is maximizing optimal pain management outcomes while minimizing opportunities for abuse. Doctors in hospitals where prescription guidelines have been rolled out report positive effects. For instance, when the head of general surgery at Dartmouth-Hitchcock Medical Center suggested that surgeons limit pain scripts to a specific number of pills for different operations, the result was impressive:
‘The number of pills prescribed by doctors for five common outpatient surgeries dropped by 53 percent, and patients didn’t consume all the pills they were given, according to a study that will be published this week [March 7, 2017] in the journal Annals of Surgery.’
‘Even veteran surgeons really had no idea how many opioids to send home with their patients, said Richard J. Barth, who is chief of general surgery at the medical center in New Hampshire and led the team that conducted the study.
“There weren’t really operation-specific guidelines out there before,” Barth said. “Doctors are very data-driven, and if there are specific guidelines, people are going to follow them.”’
This takes us from no guidelines on dose or duration to a reasonable, flexible range.
This also means punishing pill-pushing doctors–the psychiatrists and other doctors who see innumerable patients per hour, and are quick to write scripts without an understanding of the patient’s unique needs and medical history. The complement to this is moving away from a consumerist healthcare system. Dr. Marty Makary, a healthcare policy scholar and doctor at JHU, explains:
“By putting all this attention on customer satisfaction or consumer satisfaction or patient satisfaction, we’re creating a consumerist culture in healthcare. People come in, they want an antibiotic for their kid, and they don’t care what your diagnosis or explanation is, they want to walk out with that antibiotic prescription. Or you’re in pain and you want that pain script. If the doctor is under the microscope for their patient-satisfaction scores, you can imagine the perverse incentive here.”
Critics of introducing prescription guidelines and restrictions argue that such measures put unjustifiable burdens on patients with chronic pain–many of whom are on Medicaid and cannot afford to pay out of pocket for other pain management tools like physical therapy. However, proponents argue that imposing prescription restrictions is one of the few evidence-based measures available:
‘That said, given the spread of opioid abuse, using insurance rules to curtail prescribing makes sense, he said. And while evidence is limited, restricting insurance coverage generally has worked to drive down prescriptions of other particular drugs. But “these are blunt instruments,” Diaz said. “We do have to be thoughtful.”’
In addition, many doctors and patient advocates realize that not prescribing can be as bad as over-prescribing. So, prescription guidelines allow for patient-specific care, including prescription levels that deviate far from the mean when appropriate.
Yet, lagging wages and dwindling job opportunities for those of us with the least education contributes to upticks in opioid use, too. Recent research based on county-level health records from 1999 to 2014 found that as “the county unemployment rate increases 1 percentage point, the opioid death rate (per 100,000) rises by 0.19 (3.6%) and the ED [Emergency Department] visit rate for opioid overdoses (per 100,000) increases by 0.95 (7.0%).” This aligns with the commonsense notion that people often use opioids to treat their economic, financial, and personal troubles.
It is clear that these vices reflect underlying mental health concerns, and the stresses that follow from an uncertain economic future. So, does this suggest that curbing prescription rates is sufficient to solve the rising midlife white mortality and morbidity rates?
No, but it is a measure that prevents unknowing patients from becoming opioid addicts, allows for flexibility and patient-specific care, re-instills the Hippocratic Oath to do no harm.