What’s Killing Middle-Aged White Americans?

By Pat Anson, Editor

A quiet epidemic of chronic pain, suicide, alcohol abuse and drug overdoses has killed a “lost generation” of nearly half a million middle aged white Americans in the last 15 years, according to a startling new study by Princeton University researchers.

Using data culled from a variety of sources and reports, researchers found a disturbing increase in the death rate for whites aged 45 to 54. Between 1999 and 2013, the mortality rate for middle aged whites rose by 2% annually, a reversal from previous decades when their death rate declined by an average of 1.8% a year.

The spike in mortality is estimated to have led to the early deaths of 488,500 white Americans, a figure comparable to the number of deaths caused by the AIDS epidemic.

 “This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround,” researchers Anne Case and Angus Deaton wrote in the study published in the Proceedings of the National Academy of Sciences. “This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis.”

No other race or ethnic group saw such an increase in mortality. African-Americans, Hispanics and those aged 65 and older continued to see their mortality rates fall.

The rising death rate for middle-aged whites was accompanied by declines in physical health, mental health and employment, as well as increases in chronic joint pain, neck pain, sciatica and disability.

It also coincided with a sharp increase in the prescribing of opioid pain medication, and seems likely to fuel a chicken and egg debate over which came first.

“The epidemic of pain which the opioids were designed to treat is real enough, although the data here cannot establish whether the increase in opioid use or the increase in pain came first. Both increased rapidly after the mid-1990s. Pain prevalence might have been even higher without the drugs, although long-term opioid use may exacerbate pain for some, and consensus on the effectiveness and risks of long-term opioid use has been hampered by lack of research evidence,” wrote Case and Deaton.

“Pain is also a risk factor for suicide. Increased alcohol abuse and suicides are likely symptoms of the same underlying epidemic, and have increased alongside it, both temporally and spatially.”

“The findings are astonishing, and a testament to the enormous toll opioids are taking in the U.S.,” said David Juurlink, MD, who heads the Division of Clinical Pharmacology and Toxicology at the University of Toronto. “It is very difficult to argue against cause-and-effect here. In my view it is a damning indictment of the widespread use of opioids for chronic pain, and should cause prescribers and patients alike to reflect on the role of these drugs, which have essentially no evidence behind them.”

Juurlink, who is a board member of Physicians for Responsible Opioid Prescribing (PROP), is advising the Centers Disease for Disease Control and Prevention (CDC) about its draft guidelines for the prescribing of opoids. He says it’s no coincidence that deaths in middle-aged whites rose just as opioid prescribing increased.

“It is an unarguable fact that opioids play a causal role in a good many of these deaths. People have drunk alcohol to excess for millenia, and have taken benzodiazepines needlessly for decades. And yet we see a striking surge in poisoning deaths coincident with surging opioid sales,” Juurlink wrote in an email to Pain News Network.

“As for suicide, you can put me on the record as speculating that opioids trigger suicide in some patients, and perhaps quite a high number. I raise this point because it's sometimes asserted that opioids can prevent suicide in patients with chronic pain. There is no evidence that this is true, but there are ample grounds to assert that they might in fact be a component cause.”

Another recent study published in JAMA found that drug overdose deaths associated with opioids nearly doubled in the last decade, rising from 4.5 deaths per 100,000 people in 2003 to 7.8 deaths per 100,000 in 2013.

But others says opioids are the not the cause of rising deaths, but more a symptom of a deeper problem.

“I can tell you absolutely that opioids do not lead this dysfunction.  Abuse, addiction, disability, and suicide are symptoms of a failing healthcare system,” says Terri Lewis, PhD, a rehabilitation specialist and patient advocate. “This population of white Americans has also been largely uninsured or underinsured.  They turn to self medication practices that involve alcohol because that is what is available.  Their acute care is often dependent on emergency room services where there is no continuity or recovery model in place.”

Deaths Hit Least Educated Hardest

The Princeton study found that death rates related to drugs, alcohol and suicides rose for middle-aged whites at all education levels, but the largest increases were seen among those with the least education. For those with a high school degree or less, deaths caused by drug and alcohol poisoning rose fourfold; suicides rose by 81 percent; and deaths caused by liver disease and cirrhosis rose by 50 percent.

“All cause” mortality rose by 22% for this least-educated group. Those with some college education saw little change in overall death rates, and those with a bachelor's degree or higher actually saw death rates decline.

The researchers speculated that financial stress may have played a role in the rising death rate. Median household incomes of whites began falling in the late 1990s, and wage stagnation hit especially hard those with a high school or less education.

“These were folks who were also disproportionately represented in the downturn of the economy and loss of jobs from rural communities,” says Lewis. “When the economy failed, their disability and reduced level of functioning did not allow them to migrate into other locations or jobs – their educational levels and physical limitations simply imposed too much of a barrier.  The loss of employment put many onto the disability roles.” 

The rise in mortality occurred in all regions of the U.S., although suicide rates were marginally higher in the South and West than in the Midwest and Northeast. In each region, death by way of accidental drug and alcohol poisoning rose at twice the rate of suicide.

In all age groups researchers said there were marked increases in deaths related to drug and alcohol poisoning, suicide and chronic liver disease and cirrhosis. The midlife group differed only in that the number of deaths was so large that it changed the direction of their overall mortality.

If that trend is not reversed, researchers warn, there will be an enormous cost to the healthcare system. 

“A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a ‘lost generation’ whose future is less bright than those who preceded them,” they said.