Research Support. Outline of Presentation 6/1/2017

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1 Deaths of Despair in Pennsylvania and Beyond: A Demographer s Take on Drug, Alcohol, and Suicide Mortality Shannon M. Monnat Assistant Professor of Rural Sociology, Demography, and Sociology Penn State University Northeast Regional Center for Rural Development Community Assessment and Education to Promote Behavioral Health Planning and Evaluation (CAPE) Research Support USDA Economic Research Service Cooperative Agreement ( ); USDA Agricultural Experiment Station Multistate Project: W- 31, The Great Recession, its Aftermath, and Patterns of Rural and Small Town Demographic Change ; Penn State Population Research Institute (NICHD Center Core Funding: R24-HD41); Penn State Dept. of Agricultural Economics, Sociology, and Education The views expressed in this presentation are those of the author and do not necessarily represent the views of these organizations. Shannon Monnat smm67@psu.edu Outline of Presentation Trends in drug, alcohol, and suicide mortality (deaths of despair) The demography of deaths of despair (demographic and spatial differences) How did we get here? Combatting deaths of despair 1

2 Deaths Deaths Deaths 6, U.S. Drug, Alcohol, and Suicide Deaths, , 4, 3, 2, 1, Drug-Induced (Accidental or Unknown Intent) (+ 219%) Suicide (+51.3%) Alcohol-Induced (+7.4%) Data: CDC Wonder Underlying Cause of Death Files; Chart: Shannon Monnat, Drug-induced means that drugs were listed as the underlying cause of death the factor that directly contributed to the death. Suicides include intentional drug overdoses and intentional deaths from other causes. 4, 3,5 3, PA Drug, Alcohol, and Suicide Deaths, Drug-Induced (Accidental or Unknown Intent) (+248.5%) Suicide (+47.5%) Alcohol-Induced (+92.8%) 2,5 2, 1,5 1, 5 Data: CDC Wonder Underlying Cause of Death Files; Chart: Shannon Monnat, smm67@psu.edu Drug-induced means that drugs were listed as the underlying cause of death the factor that directly contributed to the death. Suicides include intentional drug overdoses and intentional deaths from other causes. 18, 16, 14, 12, 1, U.S. Total Drug, Suicide, and Alcohol Deaths, Additional Contributing Deaths Alcohol-Induced Suicide (other Cause) Suicide (Firearm) Suicide (Drug Overdose) Drug-Induced (Accidental or Unknown Intent) 8, 6, 4, 2, Data: CDC Wonder Multiple Cause of Death Files; Chart: Shannon Monnat, smm67@psu.edu 157,655 total US deaths in 215 1,932,3 total US deaths ,736 total PA deaths in ,122 total PA deaths

3 Percent Deaths per 1, Population Deaths per 1, Population Deaths per 1, Population Opioids are Largest Contributor to Drug-Related Deaths (where Specific Drug is Identified) Percentage^ of Drug-Related Deaths Involving Specific Drugs ^Sum of all drug-specific deaths adds to more than 1% because multiple drugs can be involved in a death Figures include intentional drug overdoses Heroin Opioid Analgesics Synthetic Opioids* Methadone Cocaine Benzodiazepines Unspecified Drug Data Source: CDC Wonder Multiple Cause of Death Files, Chart: Shannon Monnat, smm67@psu.edu *synthetic opioids include fentanyl opioids Opioid analgesics are natural or semi-synthetic opioids (e.g., oxycodone, hydrocodone) Synthetic opioids include fentanyl The Demography of Deaths of Despair Drug, Alcohol, and Suicide Mortality Rates by Age-Group 3 Drug-Induced Data Source: CDC WONDER Underlying Cause of Death Files, Intentional Drug Overdoes are Included in the Suicide Category 3 Alcohol-Induced Suicide

4 Deaths per 1, Deaths per 1, Deaths per 1, Mortality Rates are Higher among Whites Source: Monnat, Shannon Drugs, Alcohol, and Suicide Represent Growing Share of U.S. Mortality. National Issue Brief 112. Carsey School of Public Policy. Drug, Alcohol, and Suicide Mortality Rates by Metro Status 2 Drug-Induced 2 Alcohol-Induced Suicide Data Source: CDC Wonder Underlying Cause of Death Files, Chart: Shannon Monnat, smm67@psu.edu Intentional drug-overdoses are included in the suicide category. 4 2 Pooled Drug, Alcohol and Suicide Mortality Rate (ages -64), Data : U.S. Centers for Disease Control and Prevention. CDC Wonder. Multiple Cause of Death Files. Note: Rates are age-adjusted. 4

5 Pooled Drug, Alcohol and Suicide Mortality Rate (ages -64), Highest PA Rates -Fayette -Susquehanna -Philadelphia -Cambria Data : U.S. Centers for Disease Control and Prevention. CDC Wonder. Multiple Cause of Death Files. Note: Rates are age-adjusted. How Did We Get Here? The Spark Why are Opioids so Addictive? A drug is a drug is a drug and then there are opioids. Fred Holmquist Director at Dan Anderson Renewal Center for Addiction Treatment and Recovery Prescription Opioids Include: Fentanyl (Duragesic ) Hydrocodone (Vicodin ) Oxycodone (OxyContin ) Oxymorphone (Opana ) Propoxyphene (Darvon ) Hydromorphone (Dilaudid ) Meperidine (Demerol ) Diphenoxylate (Lomotil ) 5

6 Pain as the Fifth Vital Sign & the Introduction of OxyContin The Marketing of OxyContin Targeted the highest opioid prescribers across the country. Bonus systems for sales reps ranged from $15, to nearly $24, ($4 million total in 21). Distributed 34, starter coupons. Branded promotional items for physicians (stuffed toys, hats, CDs, tools). Sources: Quinones, Sam Dreamland: The True Tale of America s Opiate Epidemic. Waveland Press.; Zee, A.V. 29. The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. Am J Public Health 99(2). 6

7 Percent Percent Heroin Has Caught up to Prescription Opioids Percentage of Drug-Related Deaths Involving Specific Drugs 3 Heroin Opioid Analgesics opioids 2 Synthetic Opioids* 15 Methadone 1 Cocaine 5 Benzodiazepines Data Source: CDC Wonder Multiple Cause of Death Files, Chart: Shannon Monnat, smm67@psu.edu Figure excludes deaths from other drugs Figure includes intentional drug overdoses *synthetic opioids include fentanyl Opioid analgesics are natural or semi-synthetic opioids (e.g., oxycodone, hydrocodone) Synthetic opioids include fentanyl Fentanyl Confiscations (214) Source: Heroin is Involved in More Young Adult Overdoses, Prescription Opioids are Involved in More Middle/Older Age Overdoses Percentage of Drug Overdoses Involving Specific Drugs, by Age Group, Heroin Opioid Analgesics 35. Synthetic Opioids* Benzodiazepines Ages -34 Ages Ages Ages Data Source: CDC Wonder Multiple Cause of Death Files; Chart: Shannon Monnat, smm67@psu.edu Note: Deaths involving other drugs and unknown drug classifications not show in chart; multiple drugs can be involved in a death *Synthetic opioids include fentanyl 7

8 How Did We Get Here? The Kindling: Landscapes of Despair Forgotten People and Places This was not new; it had been happening for fifteen years. And there was more to it than drugs. This scourge was connected to the conflation of big forces: economics and marketing, poverty and prosperity. Forgotten places of America acted like the canaries in those now-shuttered Appalachian coal mines. Just no one in the country listened much until more respectable types sounded the same alarm. Sam Quinones Economic Decline, Cynicism, Anxiety, Stagnation, Slippage Years of decline in the blue-collar economy manifested themselves in the material prospects of Middletown s residents. The Great Recession, and the not-great recovery that followed, has hastened Middletown s downward trajectory. But there was something almost spiritual about the cynicism of the community at large, something that went much deeper than a short-term recession. J.D. Vance, Hillbilly Elegy Since 198, virtually all those I talked with felt on shaky economic ground. It was a story of unfairness and anxiety, stagnation and slippage a story in which shame was the companion to need. Arlie Hochschild 8

9 Deaths per 1, Population (age-adjusted) Deaths per 1, Population (age-adjusted) Deaths per 1, Population (age-adjusted) Mortality Rates are Higher in Counties with More Economic Distress Mean County-Level Drug, Alcohol, and Suicide Mortality Rate (26-215) by Level of Economic Distress Economic Distress Quartile 1 Quartile 2 Quartile 3 Quartile 4 Quartile 1= lowest; Quartile 4=highest Economic distress includes percent poverty, percent single parent families, percent households with public assistance, percent unemployed, percent with work disability & percent without health insurance Mortality Rates are Higher in Counties with More Economic Distress Mean County-Level Drug, Alcohol, and Suicide Mortality Rate (26-215) Poverty Rate Disability Rate Percent Unemployed Counties with Lowest Distress (Q1) Uninsured Rate Single Parent Percent w/< Families 4-year College Degree Counties with Highest Distress (Q4) Mortality Rates are Highest in Counties where Median Household Income Has Declined since Mean County-Level Drug, Alcohol, and Suicide Mortality Rate (26-215) by Median Household Income Change Median Household Income Change, Decline Small Increase Medium Increase Large Increase 9

10 Deaths per 1, Population (age-adjusted) Mortality Rates are Lowest in Counties with the Greatest Presence of Health-Promoting Promoting Institutions High Presence of Social Capital Promoting Establishments Primary Health Care Professional Shortage Area Mental Health Care Professional Shortage Area No Yes Social Capital Promoting Establishments Include: number of religious, civic, bowling, fitness, golf, and sports organizations and associations per capita Non-College Educated Whites are Far Less Positive about their Relative Standard of Living than are Blacks and Hispanics There is no group of Americans more pessimistic than working-class whites. J.D. Vance, Hillbilly Elegy Source: Cherlin, Andrew. Why are White Death Rates Rising? The New York Times. Feb 22, 216. Landscapes of Despair Luzerne County, PA Manufacturing jobs declined from 42, to 19, since 198 (55% decline). Median household income has remained stagnant since 198. Above average poverty, unemployment, and disability rates Chronic out-migration of young adults Over past 15 years, drug overdoses tripled and suicides by causes other than drugs doubled. Traditionally Democratic county that went for Obama twice and hadn t gone for a Republican since 1988 Accounted for 59% of Trump s victory margin in PA 1

11 Deaths of Despair Have Far Reaching Impacts Financial & Social Costs Medicare, Medicaid, Veteran s Administration, Social Security/Disability Workplace productivity Incarceration Foster care system Burden on first responders and health care professionals Annual financial burden of drug and alcohol abuse estimated at $442 billion Disease transmission HIV Hepatitis C Sexually transmitted infections Where Do We Go From Here? Strategies to Combat Deaths of Despair Fall into Three Baskets Prevention Supply Demand Treatment Rapid-response Long-term Harm-reduction Recovery Relapse should be viewed similarly to other chronic medical illness (i.e., diabetes, hypertension) 11

12 Preventing Substance Use Initiation Supply Reforming opioid prescribing practices (CDC opioid prescribing guidelines Prescription drug monitoring programs Prescription take-back programs Aggressive enforcement against pill mills Educating public (PSAs), medical students, and physicians (target dentists and ER docs) New approaches for chronic pain treatment Will a border wall make a difference? Demand Setting realistic expectations for children, teaching healthy coping strategies, preparing children for both disappointment and success Social cohesion, social support, and community ties are buffers against substance misuse. People need opportunities for meaning in their lives. Comprehensive strategies for job growth and skill-training, particularly in places hardest hit by declines in manufacturing and other blue-collar labor. Treatment Rapid-Response Emergency Treatment (preventing death) Naloxone (Narcan )-the overdose-reversal drug (only effective for opioid overdose) Substance abuse and mental health treatment Medication-assisted treatment for opioid use disorder (methadone, buprenorphine (Suboxone, extended-release naltrexone) Integrating drug treatment into healthcare settings (very few healthcare systems provide a full bundle of services) Harm reduction approaches (controversial) Needle/syringe programs Safe drug consumption spaces Recovery Relapse should be viewed as similar to other chronic medical illness (i.e., diabetes, hypertension) Opportunities, choices, and behaviors do not occur in a vacuum. They exit within the context of larger social structures: family, the economy, educational institutions, health care systems, political systems, social safety nets. 12

13 Moving Forward The problem is bigger than opioids Health in all policies and institutions Individual s opportunities, choices, behaviors, health, and well-being do not manifest in a vacuum. They exist within the context of larger social structures: family, the economy, educational institutions, health care systems, political systems, and community. Moving Forward The problem is bigger than opioids Health in all policies and institutions Individual s opportunities, choices, behaviors, health, and well-being do not manifest in a vacuum. They exist within the context of larger social structures: family, the economy, educational institutions, health care systems, political systems, and community. Moving Forward The problem is bigger than opioids Health in all policies and institutions Individual s opportunities, choices, behaviors, health, and well-being do not manifest in a vacuum. They exist within the context of larger social structures: family, the economy, educational institutions, health care systems, political systems, and community. 13

14 Shannon Monnat, Suggested Readings (all publicly available) Drugs, Alcohol, and Suicide Represent Growing Share of U.S. Mortality Deaths of Despair and Support for Trump in the 216 Election Drugs, Death, and Despair in New England Rural Adolescents are More Likely than their Urban Peers to Abuse Prescription Painkillers Addiction Resources PA Dept. of Drug and Alcohol Programs 14