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What “deaths of despair” can teach — and warn us — about America’s future
When Kate O’Neill wrote her sister’s obituary in October 2018, she never imagined that it would generate nationwide attention. In fact, she never thought she would ever be writing one to begin with.
Like so many other Americans, O’Neill’s sister, Madelyn Linsenmeir, had fallen victim to drug abuse.
Linsenmeir was just 30 years old when she died of a drug overdose. According to her family, Linsenmeir had first tried OxyContin at a party when she was 16 years old. Two years later, she was addicted to heroin. In and out of rehab, Linsenmeir struggled to stay sober. There were times she succeeded, such as after the birth of her son Ayden in 2011, but ultimately the addiction was too powerful, and she succumbed to her illness. It was in the following days that O’Neill’s remembrance of her sister went viral.
“It is impossible to capture a person in an obituary, and especially someone whose adult life was largely defined by drug addiction,” O’Neill wrote. “To some, Maddie was just a junkie — when they saw her addiction they stopped seeing her. And what a loss for them. Because Maddie was hilarious, and warm, and fearless, and resilient.”
Linsenmeir is yet another story in a long list of young, otherwise healthy Americans who have succumbed to drug addiction. Increasingly, the country seems to be struck by an epidemic of self-destruction, a wave of pain and misery that is sweeping across the nation.
After 11 continuous years of increase, America’s life expectancy decreased from 78.9 years in 2014 to 78.6 in 2017.
From 2006 to 2016, the age-adjusted death rate for drug overdoses in the United States increased by a startling 72 percent. Since 1999, the country’s suicide rate has increased by 33 percent. The CDC reports that in 2017 alone, 47,000 Americans committed suicide, while another 70,000 people died from drug overdoses, 80 percent of which were related to opioid abuse. For reference, this data reveals that annual drug-related deaths now exceed the death toll from the height of the AIDS epidemic in 1995.
America’s suicide rates are highest in the so-called “suicide belt,” starting in New Mexico and running all the way through Montana up to Alaska. Rates in the Midwest, particularly along the Rust Belt, are also exceptionally high. Unsurprisingly, deaths related to drug overdose in these states also exceed the national average; four of the five highest states for overdose deaths in 2016 were in the Midwest. In a region once regarded as the birthplace of the American dream, death and misery seems to be taking center stage. So what exactly is causing this sudden decline in the quality of life among these communities, and what can we learn from it?
Economics professors Anne Case and Angus Deaton first discovered a disturbing trend among non-college educated, working class, white Americans in 2015; they were dying prematurely at astonishing rates.
Case and Deaton, a pair of husband-and-wife Princeton professors, found that the death rate for non-Hispanic, white Americans had increased steadily since 1999 in contrast to gradually declining death rates among Hispanics, African-Americans and continental Europeans. They coined the term “deaths of despair” to describe the demographic’s rising death rate, attributing the increase in mortality to factors such as drug overdose, alcohol abuse and suicide. The duo identified these risk factors as proximate causes but believe more complex elements are also behind this group’s sudden stark decline in life expectancy.
Chiefly among these has been the dwindling prospects of economic opportunity for residents in the Rust Belt. While in previous generations, many non-college educated Americans found sustainable work in the region’s once-bustling steel and automotive industries, the collapse of these sectors has disenfranchised an entire generation. Between 1970 and 1990, the American worldwide share of steel production declined from 20 percent to 12 percent; American employment in this industry dropped from 400,000 to 120,000 in the same timespan. The reverberations have continued with no end in sight — since 1999, the Midwest has lost 30 percent of all manufacturing jobs.
Deaton argues that the effects of diminished financial security stretch well beyond the workplace. He notes that the region’s depressed economic opportunities have driven down its marriage rate, leading to high levels of unmarried cohabitation. Deaton believes this trend is particularly problematic as it eliminates the social support network of marriage and children once present in generations prior.
The pair also theorized that, although the region’s overall rate of religiosity has remained relatively stable, the migration toward Evangelical churches and away from community-oriented Catholic and mainline Protestant denominations has eliminated yet another form of communal identity and social capital. Evangelical Christianity’s emphasis on a personal relationship between man and God contrasts with the community-based identity traditionally found in other denominations.
Deaton calls today’s age cohort a “lost generation,” the first in which its social and economic prospects are significantly worse than their parents’. He also believes that this sort of economic disillusion was a key factor in fueling the populist primary campaigns of both Donald Trump and Bernie Sanders, whose insurgent messages against the political and financial establishment spoke to the region’s anxieties.
The pharmaceutical industry has also played a large role in driving opioid-related deaths. Consider drug giant Purdue Pharma, which first introduced the oxycodone-based drug OxyContin in 1996. Through an extensive marketing campaign targeted at the medical industry, Purdue Pharma saw OxyContin prescriptions surge from 670,000 in 1997 to 6.2 million in 2002. Overall, the annual number of opioid prescriptions rose from 76 million in 1991 to 207 million in 2013. Opioid-related death rates have rapidly escalated in correlation. The overdose rate in 2008 was nearly four times what it was in 1999; meanwhile, sales of prescription painkillers in 2010 were also four times what they were in 1998.
However, prescription drugs are not the only supply chain of narcotics fueling the opioid epidemic. Fentanyl, a highly potent opioid that is 50 to 100 times stronger than morphine, is responsible for a massive number of deaths annually in the U.S. In two years alone, nearly $800 million worth of fentanyl was sold illegally to the U.S. from China. Typically the drug is manufactured in China and shipped to Mexico, where it is smuggled across the U.S. border by drug cartels. These cartels are also responsible for the majority of heroin smuggling — levels of heroin abuse in the U.S. have correlated directly with the increase in opioid prescriptions. For many addicts, fentanyl and heroin offer cheaper and more potent substitutes to prescription drugs.
Often, the communities hit the hardest by opioid abuse have also been the ones most heavily flooded by the influx of prescription drugs. In many cases, pharmaceutical giants drowned entire communities with an unregulated supply of narcotics. When you start to dig, the numbers are startling. Over the course of six years, pharmaceutical suppliers flooded the state of West Virginia with over 780 million hydrocodone and oxycodone pills, reporters at the Charleston Gazette-Mail found. That’s over 430 pills for each person living in the state. In one particularly shocking case, the tiny town of Kermit, W.Va. (population: 392) was supplied 9.1 million pills over the course of two years.
The response of the pharmaceutical industry to accusations of its lead role in the opioid crisis has largely been one of public and political deflection. McKesson, the largest of America’s “big three” drug distributors and the fifth largest corporation in the country, responded to allegations of its complicity in the opioid crisis by fully denying any form of responsibility and blaming doctors and pharmacies for their role in prescribing its products. McKesson had previously been fined $150 million for failing to report suspicious orders to the DEA. So far in 2018 alone, pharmaceutical manufacturers have exhausted more than $133 million dollars in political lobbying efforts. For reference, gun rights lobbyists spent just over $9 million dollars in the same timespan.
Follow the money, and you will find a paper trail leading back to the financial and corporate elites who stand to benefit from overprescription — and, by extension, eradication — of America’s working poor. Alex Gorsky, the CEO of Johnson & Johnson, pocketed nearly $23 million dollars in 2017 — in spite of a series of lawsuits accusing the company of deliberately targeting the elderly with painkillers. The Sackler family, of Purdue Pharma fame, has a net worth of $13 billion. Wherever you look, it appears a group of uber-rich stands to benefit from America’s drug addiction. And the repercussions are apparent everywhere.
Undeniably, Donald Trump’s ascendancy to the presidency was launched off the backs of many of America’s working class, who felt increasingly disillusioned and abandoned both by a diversifying country and a globalizing economy. For many, Trump became a symbol of hope in a region tattered by the deterioration of community and disappearance of economic opportunity.
So when Trump harrowingly spoke of “American carnage” during his inaugural address, he targeted the plight of these communities. On the campaign trail, he gave special promise to these people by deviating from the standard Republican playbook and railing against globalization, decrying free trade agreements and promising to restore the Rust Belt economy. By spending the final days of his 2016 campaign rallying support in the states where these dilapidated communities lay, he built an untraditional coalition of white working class voters that would propel him to the presidency. And in doing so, Trump capitalized on a climate of misery that the Clinton campaign seemingly missed.
The data and demographics confirm it: the suffering and economic decline in these regions helped give way to Trump’s election, much as Case and Deaton theorized in 2016. One study by Penn State University found that Trump over-performed in the “counties with the highest drug, alcohol and suicide mortality rates.” Trump received 59.96 percent of the vote in the 693 counties with above-average opioid abuse, compared to just 38.67 percent in the 638 counties with opioid abuse rates below the national average, according to the Journal of the American Medical Association. All things considered, the same factors driving the rise in deaths of despair also gave way to the electoral path necessary for Trump’s election.
Case and Deaton suggest that, if left uncontrolled, the opioid epidemic could combine with other factors to transform American society even more drastically. In an interview with the Wall Street Journal, Case cautioned that the “250 year experiment we’ve had with democracy […] could be coming to an end.” Deaton supported Case’s warning, suggesting that a three-year decline in a modern country’s life expectancy was indicative of a fracturing society on the precipice of collapse. He suggested an event like a stock market crash or unexpected war with North Korea could ultimately combine with the opioid epidemic to destroy the final fabrics of American society.
America has tried — and failed — to combat drug epidemics in the past. When the crack/cocaine epidemic struck inner city communities in the 1980s and 90s, the U.S. government responded with a largely unsuccessful wave of tough-on-crime policies that devastated the black community and led to disproportionate rates of incarceration.
America’s failed War on Drugs merely increased the profitability of the drug trade, doing little to combat addiction. It provided traffickers with massive profit margin increases that were in turn used to further the effectiveness of their trade. Had America responded to the crack epidemic of the 80s and 90s with a more sympathetic and rehabilitative strategy, we may have been able to establish the infrastructure necessary to combat the drug problems of the present. But now we are left looking for a new set of answers.
One such solution is Medicaid expansion. The majority of nonelderly adults with opioid addiction are low income, with 28 percent living below the poverty line, according to a 2016 study by the Henry Kaiser Foundation. In 2016 those with Medicaid coverage (43 percent) were nearly twice as likely as those uninsured (23 percent) to receive addiction treatment.
The Kaiser study also found that those covered by Medicaid were nearly three times as likely as those uninsured to receive help at an outpatient rehabilitation or mental health center. This trend towards outpatient, community-based treatment is an intriguing prospect, one that has already been adopted by a number of states with a high degree of success.
Take, for example, Virginia’s Addiction and Recovery Treatment Services program, which is covered by the state’s Medicaid. Through the implementation of this program, Virginia has seen a reversal in deaths related to opioid overdose. From 2015 to 2017, opioid-related visits to Virginia emergency rooms increased by 25 percent. However, since implementing ARTS in 2017, the Department of Medical Assistance Services has reported a 34 percent reduction in opioid prescribing, a 40 percent increase in members receiving addiction treatment and a 31 percent decrease in drug abuse-related emergency room visits.
A departure from the standard procedure of free trade also provides new opportunity in combating the economic rationale behind increased deaths of despair. Already, the implications of a trade war with China have strong-armed Chinese President Xi into a stricter regulation of his country’s distribution of fentanyl — a deadly opioid which has been flooded into the U.S over the last decade. So although America will likely never be able to fully restore its once-bustling industrial base, the adoption of these policies of economic protectionism are, at the very least, likely to mitigate some of the effects that globalization has had upon manufacturing-dependent regions.
Luckily, in spite of the most polarized political climate in decades, there is still evidence that a bipartisanship approach to fighting the opioid epidemic can work. In October, President Trump signed into law the Support for Patients and Communities Act, which was passed by the Senate in a 98-1 vote. The legislation addresses a number of issues limiting the ability of local communities to fight the epidemic. For example, it reauthorizes more state-level flexibility for the Cures Act, which provides $500 million toward fighting the opioid epidemic. Other notable policy changes in the bill include better access to the anti-overdose drug naloxone for first responders and the creation of a new category of controlled substances.
While not a totally comprehensive, end-all solution to the opioid crisis, the bill provides hope that politicians can successfully cross party lines to address one of the great crises of our time. As Senator Rob Portman (R-OH) put it, the bill is a “glimmer of hope at the end of a dark tunnel.”
We can only hope that the light at the end of the tunnel is closer than it seems.
Written by: Brandon Jetter — firstname.lastname@example.org
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