The Opioid Epidemic and Lake County Ohio

Rising Morbidity and Mortality Rates in Midlife Among Non-Hispanic Whites

is the original research article which I read in April. Angus Deaton, one of the co-authors is a Noble prize winner so it was unlikely to have many flaws. Anne Case and he are both at Princeton which now has an easy read version here.

The findings are pretty well summarized by the abstract which I have abridged as follows:

1) A marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change was unique to the United States; no other rich country saw a similar turnaround. It reversed decades of progress in mortality.

2) This midlife mortality reversal was confined to white non-Hispanics. Black non-Hispanics and Hispanics at midlife, as well as those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall.

3) This increase for middle aged whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Those with less education saw the most marked increases.

4) Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability  to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population.

The authors comment that the epidemic began with an increase in prescription drug use, that migrated to heroin use, augmented recently by stronger drugs. It is possible the increased drug use followed the increased morbidity and distress, however all these preceded the financial crisis. Nevertheless, it might be related to increasing despair of the economic future. The distress includes physiological (joint pain and sciatica) and psychological aspects, e.g. greater number of suicides. There are an increasing number of people on social security disability for these issues. In the paper, the authors write that "a serious concern is that those currently in midlife will age into Medicare in worse health than the elderly of today."

On June 24th there was an expert panel presentation on what is going on in Lake County. Below the break is my summary and comments on that meeting.What is going on in your part of the country, both in terms of the problem and the response?

“Heroin, Fentanyl, and Carfentanil: The Triple Threat on Our Doorstep”

The presentation was organized by the Cleveland Clinic. They have been doing these around the Cleveland area in collaboration with local drug enforcement and drug treatment officials. It was held in a parish hall; I found out about it through the parish bulletin. 

The Doctor from the Cleveland Clinic explained how the desire for patient satisfaction ratings led physicians to abandon 20 years of careful pain management, i.e. titration until the pain is gone, and err on the side of making the patient as comfortable as possible. She pointed out the United States is one of the few countries in the world that allows extensive advertising to consumers. She also said that not everyone becomes addicted but about half do.  

The representative of the  Lake County Narcotics Agency indicated that there were 49 opioid deaths in 2014 in the county, 42 in 2015, but 88 in 2016, and we are on the way to exceeding that in 2017.

Lake County has a very sophisticated crime lab, able to detect new drugs. Ohio appears to by a primary testing ground for new drugs from other countries. In the last two years they are no longer finding pure heroin; rather it is always mixed with the more powerful drugs such as Fentanyl, and Carfentanil. The last was designed to tranquilize elephants and kills people in very small doses the size of a grain of sand. Neither the sellers, nor the consumers know what they are getting anymore. However the increasing dangers have not diminished the many eager buyers and sellers.  

The Executive Director Lake County Alcohol Drug Addiction and Mental Health Services Board talked about prevention, treatment and recovery. She emphasized that treatment noncompliance in addiction was similar to Type I diabetes, asthma and high blood pressure.  She has been doing many educational presentations and expressed her willingness to give presentations no matter the size of the audience. 

I was disappointed at the turnout; I counted only about 50 people. Some of them were from the parish but many were from outside the parish, some were professionals. The pastor did encourage people to attend but did not make it a big priority. Neither he nor any the pastoral staff whom I know were there. 

I wrote an email to my own pastor; I suggested a similar meeting be held in our parish with greater attendance. He replied that the pastoral council was considering the matter and would forward my e-mail to them. They don’t meet during the summer.  Having been on the council, it is not generally a mover and a shaker.  Attendance at council meeting is open to all the parish but no one ever attends, nor are they invited. Maybe I should invite myself if they don’t reply to me after a few monthly meetings   

The national evidence shows this has been building for a decade; it is likely to last another decade at least, and looks like it is going to get much worse before beginning to get better.  It seemed to me to be a good idea to assemble some of the relevant staff and volunteers, and reach out to members of the parish who might be interested and come up with a comprehensive parish approach to this matter that would assure that all the appropriate staff, volunteers, and members who need to understand this issue have the relevant information and tools.  

There are many issues that need to be discussed. Our excessive reliance upon pills, and our uncritical reliance upon physicians. All these people are out to make money and our health is at stake. The root causes of this are economic but in very sophisticated ways. The less educated middle aged whites who are most vulnerable are the same population that voted for Trump. The Trump voters are not the people who lost their jobs but who are afraid of losing their jobs. They are probably not the people taking the drugs but they probably know a lot of people who are on drugs.