What Can be Done About Rising ‘Deaths of Despair’?
“Deaths of despair” – lives lost to suicide, alcohol, or drug use – have risen in the U.S., and have contributed to the nation’s lower life expectancy, according to data discussed at a Wednesday briefing by the Alliance for Health Policy and the Commonwealth Fund.
Life expectancy in the U.S. dipped in 2016 to 78.6 years from 78.7 years in 2015, according to the CDC National Center for Health Statistics (NCHS). The trend signals the first year-over-year decline in life expectancy at birth since the 1960s.
If these trends continue, as early mortality data from the CDC suggests they may, average life expectancy will have fallen for 3 years consecutively for the first time since the 1918 “Spanish flu” epidemic, noted David Radley, PhD, MPH, a senior scientist at the Commonwealth Fund, and senior study director at Westat, a research agency.
The term “deaths of despair “was coined by Princeton University economists, and such causes of death have risen 51% nationally from 2005 to 2016, explained Radley, who co-authored The 2018 Scorecard on State Health System Performance.
Drug overdoses, including but not limited to deaths from opioids, are seen as the primary driver of such deaths, he stated.
Radley also noted striking variations in these deaths across the country. In 2016, West Virginia had the highest rate of deaths from drugs, alcohol, or suicide at about 83 per 100,000 people. Nebraska showed the lowest increase in rates of death in these categories with about 29 deaths per 100,000.
While heart disease and cancer are responsible for far more deaths than suicide, alcohol, or drug use, “what’s unique about these deaths of despair is that it’s the only leading cause of death that’s actually increasing,” he said, and increases are seen in every state.
At the county level, Marvin Figueroa, deputy secretary of health and human resources for the Commonwealth of Virginia noted that certain social determinants of health factor into the markedly higher rates of drug overdoses in some pockets of the country. For example, the Southwestern and Eastern corners of Virginia have higher rates of poverty and unemployment, and lower rates of high school graduation, than other areas of the state.
To address the opioids epidemic, Radley suggested increasing access to naloxone, curbing the opioid prescription rate, and expanding access to care delivery models that integrate behavioral health care into primary care.
Figueroa noted the progress Virginia has seen since implementing the Addiction and Recovery Treatment Services (ARTS) program in April 2017.
Treatment rates for Medicaid enrollees with substance use disorders increased 64%; the number of enrollees given pharmacotherapy for opioid use disorders rose 34%; and the number of practitioners offering outpatient psychotherapy or counseling more than doubled, he stated.
Briefing panelists also discussed the challenge of expanding access to buprenorphine. Anand Parekh, MD, chief medical advisor for the Bipartisan Policy Center, questioned the rationale behind requiring physicians to take an 8-hour training, and for non-physicians (physician assistants and nurse practitioners) a 24-hour training before being allowed to prescribe buprenorphine.
However, audience member Garrett Moran, Ph.D., vice president for behavioral health at Westat, noted that one-third of waivered physicians aren’t prescribing.
“A key issue here is a stigma,” Moran said.
In a follow-up email to MedPage Today, he cited research suggesting that one-third to nearly two-thirds of physicians who have waivers allowing them to prescribe buprenorphine aren’t doing so. The most frequently cited obstacle to prescribing buprenorphine among physicians who do and who don’t prescribe the medication is a “lack of mental health and psychosocial support,” Moran noted, citing a 2014 study published in the Annals of Family Medicine.
Richard McKeon, Ph.D., chief of the Suicide Prevention Branch for the Substance Abuse and Mental Health Services Administration (SAMHSA), highlighted worrisome trends in suicide rates. From 1999 to 2016, in half of all U.S. states, suicide rates have risen 30%, he said. An estimated 45,000 people died from suicide in 2016.
Suicide is now the second leading cause of death for people, ages 10-30, according to the CDC National Vital Statistics System, he noted.
Sometimes, it can be hard to distinguish between an accidental overdose death and an intentional suicide, McKeon pointed out. Anecdotally, he said he has spoken with clinicians who have saved patients with naloxone, and then been told by those patients “I wish you hadn’t brought me back.” Still, there has not been significant research in this area, McKeon noted.
One of the most challenging aspects of suicide prevention is ensuring that people who’ve attempted suicide aren’t lost in a transition, for example from the emergency department to an outpatient program. Research has shown this is a period of heightened risk, McKeon told MedPage Today after the briefing.
“Suicide risk is not on or off, it’s on a continuum … which means that rapid treatment is important,” he said, adding that one way to address this problem is with telephone-based follow-up.
The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) and SAFE VET evaluation programs have shown reduced suicidal behavior among suicidal people, after discharge using this telephonic approach. A similar study at the Department of Defense used text messaging.
McKeon also highlighted the“Perfect Depression Care” initiative at the Henry Ford Health System. Core pillars of the program include increasing access to care and preventing access to lethal means of suicide. The program also employs “drop-in group visits, same-day evaluations by a psychiatrist, and department-wide certification in cognitive behavior therapy,” according to a case study in NEJM Catalyst.
This “zero suicides” strategy has gained attention following an endorsement in the 2012 Surgeon General’s National Strategy for Suicide Prevention report.