This week we're continuing our opioid update with an episode on deaths and despair.  The category of deaths that includes drug overdoses and suicides and that are contributing to a decline in US life expectancy.
Thanks to continued support from the national institute of healthcare management this second of four episodes will dig into the data on this problem and what we might do about it.  
That's the topic of this week's healthcare triage.
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For the most part, life expectancy has been on the rise in the United States in the last sixteen years.  However, that rise began to slow in comparison to other wealthy nations until it became an overall decrease in 2014.
While many issues, including obesity, have contributed to this decrease, a large portion of it has been attributed to "death's of despair".  These deaths are associated with states of substantially increased psychological stress and result from alcoholism, drug overdoses, and suicides.  
In 2017, overdose deaths hit a new record in the United States at around seventy two thousand, becoming the leading cause of death for Americans under fifty five.  In 2018, close to forty seven thousand overdose deaths were opioid-related, with two thirds of them involving synthetic opioids.  
As we discussed in last weeks episode, steps have been taken to address overprescribing of pharmaceutical opioids; but patients who are already addicted may be turning to synthetic sources when the prescriptions are limited or cut off.  Because synthetic drugs are more potent and sometimes mixed with other substances when made illegally, they are generally deadlier than their prescription counterparts.
Between 2013 and 2018 overdose deaths associated with synthetic opioids increase from around three thousand to over twenty eight thousand!  
Part of the problem lies in opioid prescribing trends with opioid prescriptions being significantly higher in rural areas.  But beyond questionable prescription practices, many other factors have been proposed to play a role, factors that contribute to the label "deaths of despair."
One of the most prominent suggestions is that in places hit hardest by the epidemic, distress over deteriorating economic conditions coupled with inadequate formal and informational safety nets may shoulder much of the blame.  
According to the Brookings Institution; deaths of despair are highest in places where blue collar jobs like manufacturing are disappearing.
Between 1997 and 2003, approximately 1.5 million rural workers lost their jobs.  Job loss is associated with severe stress for both the individual and their families, impacting economic security, self-esteem, physical health, marital and parental discord, and likelihood to abuse alcohol and other substances.  Adjusting to job loss is typically more difficult in rural areas, which further complicates the issue. 
So, perhaps not surprisingly, deaths of despair have increased alongside job losses and the rate of overdose deaths in rural areas has been higher than that of urban areas since that of 2006.
Though overall mortality rates have increased for all races and levels of education, overdose deaths appear to be highest among white adults with less education.  This is partly due to racial disparities in medicine, because opioids have been prescribed to whites at far higher rates for a variety of race-related reasons, such as baseless stereotypes about race and drug use.  
Data suggests that racial differences and subjective well being in rural areas may also play a part.  Low income white people in rural areas report lower well being when assessing measures such as life satisfaction and levels of stress and of hope when compared to their black and Hispanic counterparts.
This appears to be associated with the data on deaths of despair.  Absence of hope reported among less educated whites lines up with CDC data on premature mortality among 35 to 64 year olds.
These difficulties are thought to be due, at least in part, to cultural differences in religiosity, connectedness, and social support. 
Though more research is needed, some have also speculated that these dissimilarities in well-being find root in the different perspectives between these groups, who have had very different experiences and economic opportunities in our country's history.  In addition, less educated whites living in rural areas are more likely to report pain, and display strong anti-goverment sentiment, making it difficult to help implement policies or programs meant to help.  
Not to be forgotten in the web of opioid use and deaths of despair is the significant relationship between opioid use, opioid use disorder and suicide.
Though its been difficult to understand the exact nature of this relationship, data suggest that some percentage of opioid overdoses involve suicidal intent.  Other data suggest that the frequency of prescription opioid misuse is significantly associated with thoughts of suicide, with individuals misusing prescription opioids being twice as likely to attempt suicide as those who did not.
While the most recent data show the first uptick in life expectancy since 2014; we still haven't fully recovered the loss.  Setteling at an average of 78.7 years compared to our high of 78.9 in 2014.  Declines in cancer death were the largest driver of the recent increase.  And while a decrease in overdose deaths played a part, the numbers are still high, and deaths from suicide remained on the rise.  
So what do we do about it?
For starters, we can avoid cutting funds to organizations like the Substance Abuse and Mental Health Services Administration, whose mission is to reduce the impact of substance abuse and mental illness in America's communities, and whose budget is repeatedly threatened by proposed cuts.  We can focus resources on financial assistance and retraining after job loss, with particular focus on the nuances of job loss in rural areas.  We should also consider investing time, energy, and money into community engagement efforts, building up informal safety nets of social support.  
Given the higher number of opioid prescriptions reported in rural areas, working on evidence based prescribing practices in these healthcare systems may also be critical.  However, for reasons discussed in our last episode this would need to be done carefully.  And we can definitely work on improving healthcare for addicted individuals.  Only one in five people in need of drug treatment in the United States will receive care, and despite data on the effectiveness of medication to alleviate addiction, only half of that one in five will receive it.  
If we refuse to effectively support people facing factors that significantly undermine their well being, and if we refuse to stretch a net under individuals in desperate circumstances, and if we refuse to provide better treatment and support to affected individuals, our resulting struggle with deaths of despair seems no wonder at all.
Next week, in episode three of this four part series we'll examine the evidence for marijuana use in battling the opioid epidemic; many advocates and more liberal marijuana laws point to it's potential for curbing opioid use, but does the data back them up?  
Tune in next week to find out.
Hey, did you enjoy this episode?  You should go check out our first episode on this new series on opioids.  It always helps if you like and subscribe down below; and you should consider goin on over to patreon.com/healthcaretriage where you can help support the show and make it bigger and better yourself.
We'd especially like to thank our research associates Joe Sevits, Josh Gister and James Glasgow, and of course, our surgeon admiral Sam.
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