Stayin' Alive

I almost wound up accidentally missing the tree for the forest by immediately posting on Ma et al's "Temporal Trends in Mortality in the United States, 1969-2013," in last week's JAMA. (You should be able to read the abstract here.) Fantastic news, it seems. During that slightly more than 4 decades, the age-adjusted death rate in the U.S. fell by 43%. Death rates were down for all major causes except for COPD, a remaining echo of the tobacco epidemic. The biggest killers, cancer and heart disease, showed big declines, although the decline for cancer has leveled off.

But, as it turns out, buried in all the good news is this rather surprising but previously overlooked nugget of ugliness, which is that the death rate for middle aged white Americans, particularly those with no more than a high school education, has been rising. Don't take this the wrong way -- African Americans are still at higher risk of death than white people. But it's quite unusual for any large demographic group in a wealthy country to have a rising death rate recently. (The collapse of the former Soviet Union resulted in elevated death rates, but it's hard to think of another example.)

What's perhaps most surprising is the reason -- suicide, alcohol and drug overdoses, and alcoholic liver disease. Part of this is that people have been reporting more chronic pain of late, and this group -- middle aged white people -- is more likely to get opioid prescriptions than are others. Apparently doctors don't think they are at risk for addiction. But opioid addiction can send people onto a profound downhill trajectory. The group seems also to be at risk for social isolation, economic deprivation, and mental distress. So yeah, it's bummer city out there for a lot of folks. Enough to kill them.