The Real Culprits in Rising White Mortality

By Zachary Siegel 02/02/16

The Times’ analysis falls short on explaining causes and conditions.

The Real Culprits in Rising White Mortality

Last November, The Fix covered the mortality discovery made by Princeton economists Anne Case and Angus Deaton, who found that lowly educated, middle-class whites, ages 45-54, are dying from suicide and overdose in rates that stunned. Like the economist and New York Times blogger Paul Krugman, I—perhaps quixotically—cited the death of the American Dream, that people are medicating sheer misery rather than pain, as the cause for so many suicides and overdose poisonings. 

This macabre story has grown in both complexity and gloom. In the same vein as the Princeton duo, the Times analyzed 60 million death certificates collected by the Centers for Disease Control and Prevention from 1990 to 2014, and found a similar trend among 25 to 34-year-old whites. Opiate overdose as well as suicide was among the culprits driving up mortality rates further down the age-span. The swath of morbidity is growing wider and wider. 

In regard to the new analysis, Dr. Case told the Times, “There’s a real rumbling that bad things are coming down the pike.” Case is a realist, not a pessimist—but what’s the difference? The statistics look grim and paint a sad portrait of America. At rates never seen before, in a majority population, people are prematurely dying from drug overdose. 

What the Times found was that fatal overdose rates for the 25 to 34-year-old group is five times its level in 1999. The overdose mortality rate for 35 to 44-year-old whites also tripled during that same period. We must also take into account the latest CDC data, that in 2004, there were 2,888 deaths from overdose in this group; in 2014, the number totaled 7,558. 

Death rates from accidental drug overdose, according to the Times, rose 400% since 1999, from six per 100,000 to 30. The suicide rate also rose to 19.5 per 100,000 from 15. The CDC also discovered heroin overdoses nationwide increased 28% from 2013 to 2014, the highest on record. 

In isolation, these mortality figures indicate the United States should either be at war or suffering from a nationwide endemic, like HIV in the late ‘80s and early ‘90s. President Obama recently tweeted “the opioid epidemic is destroying lives.” It’s sobering stuff. Give it time to sink in. 

The Real Culprits 

The Times’ analysis falls short on explaining causes and conditions. While mortality rates fall for every other population, for whites it’s steadily rising. People, understandably, want answers. 

In the New York Times article, Dr. Kolodny from the Phoenix House Foundation speculated the reason as to why only whites are seeing their mortality rate rise: “The answer is that racial stereotypes are protecting these patients from the addiction epidemic,” he said. Meaning blacks and Hispanics are not consuming prescribed painkillers at the rate of whites. 

This argument is reductive and quite simplistic. His idea of racism being a protective factor against opioid overdose is based on the notion that prescription painkillers are causing the problem. The dilemma with this analysis is that the majority of people who take prescribed painkillers do so without abusing them. There are, of course, dirty doctors who work at pill mills, that are partly responsible for the epidemic seen throughout Appalachia and South Florida, particularly Broward County. Heat maps by the Times corroborate this story. But to further problematize Dr. Kolodny’s take, the clientele at pill mills are mostly drug users, not patients in need of pain management. 

The oft-cited statistic, that 4 out 5 heroin initiates began their habit with prescription opioids can be misleading, in that the majority of these people were abusing painkillers to which they were not prescribed. Indeed, the leap from swallowing a few Vicodin to overdosing on heroin is larger than a few anecdotal stories lead us to believe. A bottle of prescribed painkillers after surgery is not likely to be the smoking gun in rising mortality. 

Two recent developments in the last decade may better explain the death phenomenon. First, if you look closely at the CDC’s data, a large percentage of overdose poisonings are drugs taken in combination with one another. The most lethal cocktail is a combination of benzodiazepines such as Xanax with powerful opioids like oxycodone. Heroin users back in the ‘80s and ‘90s were not mixing these drugs the way they are now. Personally, I’ve known several users who died from this lethal combination. The brain simply goes to sleep, forgetting to breathe. 

Of the 22,767 deaths relating to prescription drug overdose in 2013, 30%—or nearly 7,000—involved benzodiazepines. Any doctor working within reason knows not to prescribe one patient both opioids and benzodiazepines. Furthermore, legitimate pain patients rarely have a need for anti-anxiety medication. A proper public health response to this particular crisis would be to educate drug users on the inherent dangers of mixing these two drugs. 

The second explanation for rising mortality has to do with a powerful painkiller called fentanyl, which boasts potency 100 times stronger than morphine. On the street it’s often sold under the name “China White.” Rather than heroin being cut with fentanyl, it’s more like fentanyl is being cut with heroin or other diluents. 

The number of fentanyl seizures throughout the country has been on the rise. In 2012, according to the National Forensic Laboratory Information System, there were only 618 fentanyl seizures; in 2014, there were 4,585. What’s startling is that the fentanyl being seized is not diverted from the pharmaceutical industry. Rather, it’s non-pharmaceutical fentanyl (NPF); meaning it's being made in clandestine laboratories. The scene of an overdose from fentanyl is unmistakable. Victims rarely have enough time to pull the needle out of their arm—it’s that instantaneous. 

There are no accurate statistics as to how many people have died from fentanyl overdose, which makes it a likely culprit in rising mortality. A recent DEA report noted that the “true number [of overdoses] is most likely higher because many coroners' offices and state crime laboratories do not test for fentanyl or its analogs unless given a specific reason to do so.”

There is a new culture of drug use that must be understood before being able to understand what is, in fact, causing the overdose deaths. Rather than blaming doctors and pain patients for the epidemic, drug users must be educated on the dangers of mixing powerful opioids with benzodiazepines. Furthermore, drug war tactics are making drug use inherently more dangerous. Like a game of whack-a-mole, once painkillers are stomped out, heroin became the logical next drug of choice. And once heroin is stomped out, people will move toward illicit fentanyl, even more dangerous than heroin. It’s an endless, unwinnable game. 

The Storm was Predicted 

The record-breaking numbers leave some experts scratching their heads, wondering how this problem became so gigantic. For others, not so much. It was actually predicted in the early 2000s that the U.S. would see a massive rise in opiate use that would result in rising overdose fatalities. 

“Heroin use in the United States and the number of new initiates have been relatively flat,” said Dave Murray of the U.S. Office of National Drug Control Policy (ONDCP), in a 2004 report by NBC. “… I don't think there's much that's new. We have a reasonably good picture of heroin use in the U.S. as relatively unchanged in the last decade.” Clearly, Murray and the ONDCP were dead wrong. 

That same report, however, interviewed Kathie Kane-Willis from Roosevelt University’s Illinois Consortium on Drug Policy. Her team has had their fingers on the opiate pulse for decades and saw the bubble rising before most. 

Back in the late ‘80s, when Kane-Willis was using heroin in New York, she felt instinctively that the demographics were changing. She told The Fix, “When I went to treatment I said that this would spread, that it’s going to move out to the suburbs—it’s going to hit the Midwest. And my psychologist said, 'No, you’re just saying that so you can feel better about what you did.'” 

At Roosevelt, Kane-Willis and her colleagues analyzed hospital discharges and treatment admissions, among other things. What they saw between 1996 and 2002 was a rising number of patients being discharged for opiate-related problems as well as a rising number of treatment admissions for heroin. “We spent a lot of time thinking, is this a blip in the data or is this really a pattern? Is it really happening and why would it be happening?” she said. 

“It’s like putting together a puzzle, and when the pieces came together we could see that this was going to become a problem.” Only nobody listened, and the ONDCP as well as other government agencies carried on without putting proper resources into opioid and heroin education and policy. “It’s sad this many people had to die to get everyone’s attention,” said Kane-Willis. 

The Necessary Response 

The current opiate epidemic has been compared to the HIV outbreak America saw in the late ‘80s and early ‘90s. There are a few major differences, though. Mainly, the FDA has already approved necessary drugs to solve the problem: methadone, Suboxone, naltrexone, and naloxone. 

A recent longitudinal study in Baltimore—at one point dubbed America’s heroin capital—found: “Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths,” therefore, “implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths.” 

Obama’s tweet about the opioid epidemic also exclaimed that treatment must be within everyone’s reach. However, applying the old abstinence-model to this new problem is the wrong course of action. For alcoholics, 12 steps and support groups might have been the answer. But for young heroin users, they need medicine and a public health response in the form of expanded medical services in conjunction with community support. 

If we’re going to compare the opiate crisis to the AIDS epidemic, we must then respond as such.

Please read our comment policy. - The Fix

Zachary Siegel is a freelance journalist specializing in science, health and drug policy. His reporting has also appeared in Slate, The Daily Beast, Salon, Huffington Post, among others. He writes often about addiction, sometimes drawing from his own experience. You can find out more about Zachary on Linkedin or follow him on Twitter.