Opioids, opioids, opioids: The plague among middle-aged white Americans.

Nearly 30% of outpatient opioid prescriptions in the United States have no documented clinical reason to justify the use of the drugs. This is shown in a recent analysis of physician visit records by researchers at Harvard Medical School and the RAND Corporation published in September 2018 (Tisamarie, Sabety, & Maestas, 2018).

The results are not that surprising to anyone familiar with the ongoing American opioid crisis. This is a crisis entailing the misuse of prescription painkillers, heroin, and synthetic opiates such as fentanyl. The increased prescription of opioid-based medical drugs began in the 1990s after Big Pharma had publicly assured that the drugs would not lead to addiction. Today, 25% of American heroin users started out with prescription opioids (Jones, 2013). Each day, at least 115 Americans die of an opioid overdose (CDC/NCHS, 2017).

As is so often the case with scholars in the field of addiction research, misery draws our attention and interest: the opioid crisis was basically why I applied for entry into a visiting scholar programme to work in Boston in the autumn of 2018. My interest was not so much in the drug epidemic as such as in the new ways in which it was part of a stratification of the population.

Why are middle-aged whites dying?

Around the turn of the millennium, mortality rates in the US started to increase among the non-Hispanic white population of middle-aged women and men. When Princeton professors Anne Case and Angus Deaton famously published their article in 2015 about the phenomenon (Case & Deaton, 2015), the results started a media wildfire. The study showed that opioid misuse, alcoholism, and suicide were the most salient reasons behind the trends. It was covered in The New York Times at the time:Something was happening that had never been witnessed before. The increase in ill health and mortality among this population segment during 1999–2013 was unique. The explanations offered were alcohol- and drug-related, suicide, chronic liver illnesses, and cirrhosis. The background was to be found in substance-use-related suicide waves, alcohol-related illnesses, and overdoses of heroin and prescription opiates. Until then the most common death causes in this age group had been cancer, and heart and coronary diseases (Case & Deaton, 2015).

Something startling is happening to middle-aged white Americans. Unlike every other age group, unlike every other racial and ethnic group, unlike their counterparts in other rich countries, death rates in this group have been rising, not falling. (Kolata, 2015)

The 2015 analysis by Case and Deaton suggested some reasons for the declining trend in health and welfare among the less-educated white American population. The trend had been puzzling demographers for a while. In fact, this segment of the white American population now die so rapidly that they raise the numbers for the whole age segment. The mortality for Caucasians aged 45 to 54 years who only have a high school degree increased on average by 134 individuals per every 100,000 between 1999 and 2014.

In a follow-up study in 2017 the researchers updated and broadened their scope in the quest for some structural reasons (Case & Deaton, 2017). They concluded that the wave of “death from despair” (alcohol- and drug-related causes plus suicide) originates from a long-lived cumulative trend of unfavourable circumstances for less-educated white Americans. This is due to the development of the labour market, but marital circumstances,[1] reproduction, and religion also play a part in the equation. While the researchers deemed the availability of opiates as a fundamental reason, they also saw that the prescription of opiates for chronic pain added fuel to the fire, worsening the epidemic. If the researchers’ analysis holds true – which is very likely – it will take a long time for political instruments to turn the trend. Those in the middle age of this segment today cannot expect prosperity after the age of 65, conclude Case and Deaton.

In their 2017 article, Case and Deaton reason extensively around possible explanations. They trial and often reject a range of reasons statistically in the light of different data and historical examples of how corresponding developments have occurred. They reject the explanatory model of declining incomes and stagnating median wages and median family incomes. Historically, mortality and ill health have only randomly correlated with changes in incomes. Unemployment is similarly rejected as an underlying cause, because it has declined during the 2000s and remarkably so even when the mortality rate was rising dramatically due to the opioid crisis in the 2000s.

In their attempt to shed some light on their results, Case and Deaton (2017) also refer to the extensive literature about how good economic times actually often correlate with less good health on an aggregated level. Their interpretation is that even if there might have been some sort of genuinely positive effect on the individual level between income and health, the positive effect was swallowed up by other macro factors at the aggregated level.

Neither the increase in “deaths of despair” nor the decrease in coronary-related disease seems to hold any correlations with incomes. In short, the researchers conclude that they do not know how to explain the decrease in well-being and health and the increase in mortality that they observe in this segment of the population.

The relative feeling of agency

The interesting part of the study comes toward the end of the 2017 article where the authors take on a “perspective of perception on life” by the generation under study. This is related to developments in other parts of the population, showing how feelings about and beliefs in own agency in comparison to others’ situations may come to be affected in some historical circumstances. This discussion also keeps occurring in addiction research (see Hellman, 2017). In the United States, the decreasing income gap between the black and the white population in the 1960s and 1970s induced hope for the black population, and many Hispanics were experiencing better life conditions than their parent generation. The researchers cite Emory University historian and author of the book White rage (2016) Carol Anderson, who in an interview with POLITICO Magazine (Glasser & Thrush, 2016) explains that “If you’ve always been privileged, equality begins to look like oppression”, and contrasts the pessimism among whites with the “sense of hopefulness, that sense of what America could be, that has been driving black folk for centuries”. That hopefulness is consistent with the much lower suicide rates among blacks, but it is hard to verify such accounts with the data beyond that suggestive level.

The trends related to and induced by opioid and other substance use in this and other parts of the American population continue to puzzle researchers. The American political climate lends some credibility to Anderson’s explanation: the privileged may no longer feel privileged, and it may be this circumstance that we are witnessing as a part of the declining health and longevity among some white Americans. The state of health is underpinned by cultural and historical social identity.

Issue 5 2018

In this issue of Nordic Studies on Alcohol and Drugs we focus on rather different Nordic substance use phenomena in five research reports.

Rautiainen, Ryynänen, and Laatikainen (2018) look at the outcomes of working-age treatment patients with alcohol-use disorder. This North Karelian study provides evidence of the great severity of problems and relatively weak prospects of recovery for this care population. North Karelia is known as a setting from public health projects in the past that have been successful by targeting combinations of different lifestyle-related problems.

Relationships between such behaviours, namely between smoking cessation and weight concerns, are accounted for on the population level in Finnish data sets in an article by Tuovinen and colleagues (2018). The study shows an association between success in quitting smoking and a higher degree of weight concerns, and concludes that weight concern is a relevant dimension to embed in quitting support.

A longitudinal study by Norwegian researchers (Heradstveit et al., 2018) contributes to our knowledge about the externalising and internalising of alcohol and drug use during childhood and adolescence, and about the level of substance use. As expected, internalisation of use is more commonly associated with own use. Another Norwegian study pays attention to a later stage of youth, exploring the prevalence and correlates of cognitive enhancement use of stimulants and depressants among students (Myrseth, Pallesen, Torsheim, & Erevik, 2018). The use of pharmacological cognitive enhancement (PCE) can, according to the authors, be explained by a combination of wanting to improve academic achievement and a general inclination towards substance use. The two-wave study shows, for example, that stimulant users tend to be more antisocial and indifferent to rules, whereas depressant users tend to focus more on coping with stress.

In a Swedish policy-related pre- and post-evaluation of a change in opening hours in Visby, the study by Norström, Ramstedt, and Svensson (2018) provides evidence of some positive outcomes, and explains these in the light of the existing research literature and on the basis of interviews with professionals in the municipality.