What's killing white Americans?

Op-ed: For the first time in decades the life expectancy of whites is falling. Why? What changed?

For the first time in decades the life expectancy of whites is falling, particularly among women, the middle aged and those with little education. One study by two Princeton economists found that in 1999, decades of falling mortality statistics for American middle aged whites reversed course, began heading up, and have kept climbing ever since. Why? What changed?

It was at this same time that pharmaceutical companies began a successful campaign to mass-market opioid pain relievers like OxyContin, Vicodin and Percocet, resulting in a 400 percent increase in their use between 1999 and 2010. Before 1999, use of prescription pain medications was mostly limited to cancer those recovering from surgery. Through aggressive and misleading marketing to physicians the pharmaceutical industry succeeded in changing the medical culture. They faked their data to "prove" opioids had no addiction risk. (In 2007, Purdue Pharma, the makers of OxyContin, pleaded guilty to criminal charges for this fraud.) Freedom from pain became a new patient right, and doctors were instructed to measure pain with new scales ranging from smiley faces to frowns, and medicate until no one was left frowning.

But can we really connect the rise in opioids to this public health crisis? Evidence suggests we can.

The first clue is the cause of death. The traditional killers like cancer, diabetes and heart disease have remained relatively constant while statistically, one of the biggest contributors to increased mortality among whites comes directly from prescription opioid drug overdoses, which have quadrupled since 1999. The other major causes are heroin related deaths, suicides and alcohol abuse.

Opioids have a strong role in the surge in heroin use among whites. Opioids and heroin stimulate the same opiate receptors in the brain. When people become hooked on prescription opiates, and then can't obtain or afford them — especially because doctors are now trying to reign in overprescribing — they turn to heroin, which is a cheaper and readily available substitute. Opioids, not marijuana as we were once told, are the real gateway drugs that lead to heroin addiction.

Particularly alarming has been the dramatic rise in suicide in this population. In addition to the growing number of people who intentionally overdose on these drugs, they push many more toward suicide. A Johns Hopkins study found that patients who took prescribed opioids for two years were four times as likely to contemplate suicide as those who did not use them. And those who abused them without a prescription were eight times more likely. This comes as no surprise to clinicians who see that these drugs make people less active, more isolated, more depressed and more impulsive and impair their judgment — all of which increase the risk that the user will take his or her own life.

There are also undoubtedly other deaths opioids contribute to that we will never be able to directly tie to them, such as car accidents under the influence, drug interactions, medical conditions worsened by these drugs and their negative effects on lifestyle behavior — such as decreasing activity level — which indirectly contribute to death.

The second clue that opioids are to blame is that death rates have risen among the groups who use opioids the most and fallen among those who use them the least. The white groups who have seen the biggest increase in deaths are also the groups who are prescribed the most opioids: women, the middle aged and the less educated. In contrast, African-Americans and Latino-Americans are prescribed opioids less often than whites, even when they are in the same amount of pain (which ironically could be a result of a racial stereotype that they are more drug seeking), and they, unlike whites, have continued to enjoy increasing longevity. To look at an international comparison, among all the rich nations of the world other than the United States, death rates have continued to fall 2 percent a year, as ours once did. Not coincidentally, Americans use opioids at five times the rate of Canadians and 10 times the rate of Western Europeans.

If death rates had continued to fall 2 percent a year for American whites, as they have for all other rich nations, 500,000 people could have been spared a premature death over the last 15 years. Ironically, greed and deceptive marketing by an industry we entrust with our health has unleashed the biggest public health crisis of our generation. No doubt, hundreds of thousands of current and future patients will die unnecessarily, while Big Pharma makes billions selling them opioids.

John Gartner is a self-employed psychologist who taught psychiatry at Johns Hopkins Medical School for 28 years. His email is johndgartner@comcast.net.

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