LR

Deaths of Despair — Detailed Lecture Notes

Introduction & Webinar Context

  • Presenter: Shannon Monnat – Assistant Professor of Rural Sociology, Demography, and Sociology at Penn State.
  • Topic: “Deaths of Despair: Drug, Alcohol, and Suicide Mortality in Small-City and Rural America.”
  • Webinar hosted by the Institute for Research on Poverty; recording available on IRP site & YouTube.
  • Funding acknowledgments (HHS/ASPE); views expressed are the presenter’s own.
  • Emphasis on how place (rural vs. urban, small cities) shapes health disparities.
  • Outline of talk:
    • Trends in drug, alcohol, and suicide mortality ("deaths of despair").
    • Demographic & spatial variation.
    • "Spark" (opioid availability) vs. underlying "kindling" (economic & social distress).
    • Strategies for prevention, treatment, recovery.

National Mortality Trends ( 1999\text{–}2015 )

  • Drug‐induced deaths more than tripled since 1999.
    • Nearly 50{,}000 drug deaths in 2015 alone.
    • Growth curve parallels HIV/AIDS epidemic of late 1980\text{s}–early 1990\text{s}.
  • Suicide deaths ↑ ≈ 50\% since 1999.
    • Intentional overdose = small share; firearms dominate.
  • Alcohol‐induced deaths (esp. cirrhosis) ↑ ≈ 70\% since 1999.
  • Combined direct deaths (drug + alcohol + suicide): >127{,}000 in 2015; >1.5\;\text{million} across 1999\text{–}2015.
  • When drugs/alcohol/suicide listed as contributing cause: >157{,}000 deaths in 2015; ≈2\;\text{million} total 1999\text{–}2015.

Which Drugs Are Killing?

  • Majority of death certificates list “unspecified/unknown” drug.
  • Among specified cases, opioids dominate:
    • Prescription pain-killers, heroin, methadone, synthetic opioids (e.g., fentanyl).
    • U.S. = <5\% of world population but >80\% of global prescription opioid consumption; 99\% of hydrocodone market.
    • Fentanyl potency: 50\text{–}100\times morphine.
  • Noticeable surges:
    • Heroin share spikes after 2010.
    • Synthetic opioids (fentanyl) spike after 2013.
    • Rising benzodiazepine involvement (anxiety/sleep meds).

Demographic Patterns

  • Race × Sex (Age-adjusted rates)
    • Until 2007: highest drug mortality = Black males.
    • Post-2007: White males highest; White females rising fastest (now exceed Black & Hispanic females and Hispanic males).
    • Alcohol-induced deaths declining for Blacks & Hispanics; rising for Whites (m & f). American Indians possess the overall highest alcohol & drug rates (data not graphed).
    • Suicide increases limited to Whites (m & f); stable for Black & Hispanic groups.

Age-Specific Patterns

  • Drug deaths lowest in 15\text{–}24 group; highest in 45\text{–}54; sharp upticks in 25\text{–}34 & 35\text{–}44.
  • Alcohol deaths peak in 55\text{–}64 (Baby Boom cohort) — consistent with long-term heavy drinking → cirrhosis.
  • Suicides: top in 45\text{–}54, followed by 55\text{–}64; rising across all adult ages since 1999.

Spatial Patterns

  • Metro status (ages 25\text{–}54):
    • Large urban counties (≥1\;\text{million} ppl) now have lower drug death rates than small urban & rural counties.
    • Same rural disadvantage for alcohol and suicide.
  • State rankings shift: 1999\text{–}2001 top rates in urbanized D.C., MD, AZ, NJ; 2013\text{–}2015 led by less-urban WV, KY, NH.
  • County hotspots (high combined drug + alcohol + suicide, ages 25\text{–}64): New England, Appalachia, Industrial Midwest/Rust Belt, Oklahoma, Desert Southwest/Mountain West, Northern CA & Pacific NW.

Opioid Pharmacology & Addictiveness (“The Spark”)

  • Morphine molecule fits μ-opioid receptors in brain, spine, GI tract → extreme euphoria & analgesia.
  • High-dose, long-term use ↓ body’s natural endorphin production → severe withdrawal (pain, diarrhea, insomnia) when stopped.
  • Rapid tolerance escalation; relapse risk: original “habit dose” now lethal → respiratory depression, death.
  • Sam Quinones: opioids = “poster child of the American age of excess.”

Prescription Era & Pill Mills

  • Pre-1990: opioids reserved for trauma/cancer.
  • Early 1990\text{s}: “Pain = 5th vital sign” campaign; doctors urged to ask every patient.
  • 1996: Purdue launches OxyContin (extended-release oxycodone); claims of low addiction risk.
    • Aggressive marketing to manual-labor & retiree regions (Appalachia, Mountain West, FL).
  • Pill mills: cash-only clinics dispensing hundreds of pills with minimal diagnosis; first rampant in OH, KY, WV → migrated to FL (I-75 “Oxy Express”). Broward County once had more pill mills than McDonald’s.

Shift to Heroin & Fentanyl

  • Crack-down on prescriptions (PDMPs, stricter laws) → many users switch to cheaper, potent heroin (often laced w/ fentanyl).
  • Age divergence:
    • Heroin‐related deaths disproportionately 25\text{–}34.
    • Rx-opioid deaths heaviest in 45+ cohorts.
  • Young-adult pathways: leftover dental/surgery meds, peer experimentation; limited Rx access → heroin “cheaper than a six-pack” in PA.

"Kindling": Economic, Social & Political Stressors

  • Trend occurs amid falling mortality for heart disease, diabetes, MVCs, most cancers → indicates distinctive etiology.
  • Structural forces:
    • Globalization & de-industrialization.
    • Rising income inequality; policy preference for markets over welfare state.
    • Literature links: J.D. Vance (Hillbilly Elegy), Arlie Hochschild (Strangers in Their Own Land), Case & Deaton (“Deaths of Despair”).
  • Case & Deaton: declining age-premium to wages; weaker labor-force attachment → cascades to family instability & health.

Statistical Evidence Linking Distress & Mortality

  • Economic Distress Index (poverty, disability, unemployment, uninsured, single-parent families, % no BA):
    • Counties in top distress quartile show highest average drug + alcohol + suicide rates.
  • Declining real median income (since 1980) → markedly higher mortality.
  • Social capital institutions (churches, civic clubs) scarce → higher deaths; similar effect for health-professional shortage areas.
  • Racial/Ethnic composition:
    • Higher % Non-Hispanic White → higher mortality.
    • Higher % Black → lower mortality.
    • % Immigrant not associated with higher deaths.
    • Counties with largest % American Indian populations → highest rates.
  • Paradox: Blacks face greater material hardship yet lower deaths of despair; possible factors:
    • Lower opioid prescribing to Black patients.
    • Different mental-health reporting patterns.
    • Reference-group theory: Whites compare to a more prosperous parental cohort; Blacks/Hispanics compare to ancestors with fewer opportunities → divergent optimism.

County Case Study – Luzerne County, PA

  • Manufacturing jobs ↓ from 42{,}000 (≈1980) → <19{,}000 today.
  • Median household income stagnant vs. rising living costs.
  • >25\% of adults 25\text{–}59 unemployed or out of labor force; chronic youth out-migration (selective for those w/ resources).
  • Drug overdose deaths tripled; suicides doubled in ~15 years.
  • Symbolizes broader small-city/rural decline; contributed to political shift (Trump carried county, first GOP win since 1988).

Broader Consequences

  • Ripple effects span:
    • Child welfare (surge in foster placements).
    • Workplace productivity (hiring challenges due to failed drug tests).
    • First-responder burnout & ED overcrowding.
  • Economic cost borne by entire society, not just users/families.

Strategies & Interventions

  • Comprehensive tri-part strategy: Prevention + Treatment + Recovery.

1. Prevention (Demand & Supply)

  • Prescription Drug Monitoring Programs (PDMPs); reform prescribing guidelines.
  • Curtailing heroin via border wall unlikely (synthetic fentanyl produced in U.S. labs; imports from China).
  • Youth-focused primary prevention crucial – stop initiation.

2. Treatment

  • Naloxone (Narcan) expansion saves lives but insufficient alone (“we can’t Narcan our way out”).
  • Increase access to Medication-Assisted Treatment (MAT) and wrap-around services.
  • Address polysubstance risk (benzodiazepines, alcohol) – Narcan ineffective here.

3. Harm Reduction & Long-Term Recovery

  • Needle exchanges, safe‐injection sites, fentanyl test strips – evidence-based but politically contentious.
  • View substance-use disorder as chronic disease; relapse akin to diabetes/hypertension non-compliance.
  • Recovery supported by robust social structures: employment opportunities, stable housing, community networks.

Overarching Policy Implications

  • Opioids are the canary in the coal mine; underlying crisis = economic dislocation, social fragmentation, individualism.
  • Good economic, social, and criminal-justice policy = good public-health policy.
  • U.S. “go-it-alone” culture magnifies isolation; collective solutions (community engagement, safety nets) are protective.
  • Outcome goals must be specified: reduce mortality? reduce use? improve quality of life? – policy design follows.

Suggested Readings & Resources

  • S. Monnat publications (Carsey School briefs; demography articles).
  • S. Quinones, Dreamland (detailed opioid history & narratives).
  • Case & Deaton papers on midlife mortality.
  • J.D. Vance, Hillbilly Elegy; A. Hochschild, Strangers in Their Own Land.
  • CDC WONDER mortality database; National Center for Health Statistics.
  • Harm reduction organizations: Harm Reduction Coalition, North American Syringe Exchange Network.