We have long expected to see increasing substance use in middle and later life with the aging of baby boomers—a demographic that traditionally had a more relaxed attitude to substance use. A recent study funded by the National Institute on Aging reveals the unexpected enormity of the problem and its disastrous consequences for a generation of Americans.
In an article published last month in the Proceedings of the National Academy of Sciences, Princeton University economists Anne Case and Angus Deaton (who won last year’s Nobel prize in economics for his research on poverty) identified an anomalous trend of increased all-cause mortality among white non-Hispanic, middle-aged (ages 45-55) Americans between 1999 and 2013 that appears mainly attributable to the devastating impact of substance use and emotional distress. Drug and alcohol poisonings and suicides accounted for most of the increased mortality; death from chronic liver diseases, which are associated with alcohol abuse, also rose in this population.
Deaths from these causes also increased in other age groups, but it was only in the 45-55 age group that they were sufficient to raise all-cause mortality. The increased mortality was most pronounced among those with lower educational attainment. In this day and age of increased longevity and advances in healthcare, any reversal of the overall downward trend in mortality and morbidity is alarming. Across the decade and a half of the study, most other age groups and ethnicities continued to see declines in mortality, as did European whites in the same age bracket. Had mortality continued to decline for non-Hispanic whites in this age bracket at the rate seen in the previous two decades, half a million deaths would have been avoided during this period.
The mortality increases paralleled increased self-reports of poor health, pain, psychological distress, and difficulties with activities of daily living (sitting, walking, shopping, socializing with friends) in this population—all of which may be linked to substance abuse. The time period of the study also corresponded to the escalating use of prescription opioids, which have been responsible for most of the drug poisonings. (More than 16,000 people died from prescription opioid overdoses in 2013.) This year, the Department of Health and Human Services and the White House announced multi-pronged initiatives to combat prescription opioid and heroin addiction and associated overdose deaths. But the PNAS study shows that the opioid epidemic may be part of a larger problem of increased distress among middle-aged whites. Stress and negative emotional states are well documented to contribute to the emergence of drug and alcohol use disorders, via a process of negative reinforcement.
A major driver of the opioid epidemic was the rise in opioid prescribing for chronic pain starting in the late 1990s. The associations between drug- and alcohol-related mortality, pain, and mental health led Case and Deaton to hypothesize that a number of contextual factors, including growing financial insecurity and declining economic prospects for baby boomers in the last two decades, may be involved. The resulting substance abuse and other mental and physical health problems may be leading, they fear, to a “lost generation” that may look forward to a less healthy as well as less prosperous future than their parents, and that may be a major drain on Medicare and disability funds in coming years.
Although we are accustomed to thinking about preventive interventions for youth, it is clearly necessary to also consider how we can prevent drug and alcohol abuse in middle age and older Americans. These findings argue for greater integration of screening as well as drug and alcohol messaging in primary medicine. Primary care physicians are in a unique position not only to ask about substance use and track their patients’ use from visit to visit, but also to educate their patients about safe levels of alcohol use and the dangers of misuse of other substances. Since drug and alcohol use disorders often appear in tandem with pain and mental distress, providers may see these symptoms as warning signs, indicating a need to also pay attention to drug and alcohol misuse and not shy away from difficult conversations about these serious threats to those patients’ health and well-being.