Friday, December 25, 2015

“Half a million people are dead who should not be dead.”

In November 2015, two Princeton economists, Anne Case and Angus Deaton, published a report analyzing mortality rates among Americans from 1999 to 2013. Their findings violently overturned our fundamental expectations for life expectancy in 21st-century America: For 14 years, the mortality rate among white Americans age 45 to 54 rose, half a percent every year. According to Case and Deaton, if mortality rates had simply held steady at their 1998 number, there would have been 96,000 fewer deaths from 1999 to 2013. Further, if the mortality rates had continued to steadily decline as they had in the second half of the 20th century—and as is typical of industrialized countries—488,500 deaths could have been prevented over that 14-year period. As Deaton told The Washington Post, “Half a million people are dead who should not be dead.”

In a commentary on the study, Dartmouth economists Jonathan Skinner and Ellen Meara observed that “it is difficult to find modern settings with survival losses of this magnitude.” Skinner says the U.S. mortality figures are unique even among other epidemiological crises: Compared with, say, the crack cocaine epidemic of the 1980s, the HIV crisis, and even the mass deaths of Russian men in the 1990s, the current trend is unprecedented in its abrupt and unforeseen arrival. “There were a few studies that kind of hinted at it, but to find this rise in mortality where people didn’t even know why, there’s nothing that you can point to where you can say, ‘Oh my gosh, this is why this is happening,’” he says.

When Case and Deaton’s study was published in Proceedings of the National Academy of Sciences in early November, the intelligentsia slipped into a kind of paranoid rapture. Journalists, pundits and op-ed potentates came out in droves to offer their takes on the dismaying statistics. There are some clear hints as to what was going on: The data show that the uptick in deaths was primarily from drug and alcohol poisonings and suicides, with liver disease a somewhat distant third culprit. But there was no clear explanation for why middle-age white Americans were overdosing and killing themselves at such unprecedented rates. So many treated the study as a canvas upon which any and all of the popular American end-of-days narratives could be painted: loss of religion; decline in marriages; disintegration of good middle-class jobs; the end of the blue collar–led household due to wage stagnation; even, more quixotically, the broken promise of the American dream.

But many of the factors pointed to—especially economic considerations like frozen wages, unemployment and the disappearance of well-paying jobs that didn’t require a college degree—affected blacks and Hispanics in the U.S. even worse than they did whites. Yet mortality rates in those demographic groups have continued to fall. White middle-age Americans still have a lower mortality rate than, for example, middle-age blacks—415 per 100,000, compared with 581. But that difference is significantly smaller than it was 15 years ago, as black mortality in the 45-to-54 age group has fallen 2.6 percent per year since 1999, while that of their white counterparts rose. And European countries were racked by arguably even worse economic hardship than the U.S. in the past decade—but their mortality rates have likewise declined, in keeping with historical trends. Middle-age white Americans’ mortality now lags well behind both Hispanics in the U.S. and corresponding age groups in France, Germany, Canada, the U.K. and other industrialized countries. Apply a bit of analytical rigor and the economics argument doesn’t hold up.

Speculators were also quick to interpret the mortality figures as specifically a white man’s problem—all the better to suit journalists’ characterization of disillusioned former breadwinners made impotent by growing income inequality.  But the numbers undercut that argument: Columbia statistics professor Andrew Gelman sifted Case and Deaton’s data to separate the mortality rates for gender, and he found that women have been dying at a higher rate than men ages 45 to 54 since 1999, with the most pronounced spike coming after 2006. This data crunch sabotaged the neat and widely popularized idea that the dying were grievously disaffected middle-age white men, broken by the revelation that the American dream was a lie.
There is, however, something that does make white men and women in the U.S. unique compared with other demographics around the world: their consumption of prescription opioids. Although the U.S. constitutes only 4.6 percent of the world’s population, Americans use 80 percent of the world’s opioids. As Skinner and Meara point out in their study, a disproportionate amount of these opioid users are white, and past studies have shown that doctors are much more willing to treat pain in white patients than in blacks...

Today, drug overdose deaths from both prescription opioids and heroin continue their sharp climb in every age group. But the OxyContin Wild West of the 2000s was not just about skyrocketing overdoses—the overprescription of OxyContin, Vicodin and Percocet also spread the intractable disease of addiction. As Case and Deaton point out in their study, for every fatal painkiller overdose, there are 130 people addicted to prescription opioids.

“Mortality is the canary in the coal mine,” says Skinner. The fact that heroin overdoses nationwide increased 28 percent from 2013 to 2014 (with an accompanying 16 percent hike in prescription painkiller deaths) means there are hundreds of thousands of addicts behind those fatalities, who are not only one wrong fix from death but are also saddled with addiction for life. And heroin addiction taken as a whole, Skinner says, is arguably even more pernicious than the deaths it can cause: It can tear families and communities apart, harming many more people than just the actual addicts.

Efforts are underway to fight the onslaught of prescription drugs and the sprawling heroin epidemic. Michael Botticelli, director of the Office of National Drug Control Policy in Washington, says his office has led an aggressive expansion of state-based prescription drug monitoring systems, allowing health care providers to identify potential abusers jumping from doctor to doctor to feed their addiction. The office focuses on educating prescribers about the perils of opioids. Botticelli has also led efforts to improve access to treatment for addicts, including bolstering distribution of naloxone, which reverses the effects of an opioid overdose. But perhaps most promising are the recently drafted CDC guidelines for opioid prescribers, urging doctors to weigh the risks of dependency and abuse whenever prescribing opioids. The CDC recommends “three or fewer days” of opioid treatment under most circumstances—a long way from the 30- and even 90-day supplies patients have been able to obtain. While CDC guidelines are not binding, they are oft-cited and widely followed in the medical community.

Of course, while there is always a place for both triage and more stringent prescriber guidelines, such efforts won’t cut off these drugs at the source. And pharmaceutical companies like Purdue, Endo, Johnson & Johnson and Abbott Labs have little incentive to reduce the sales of their pain pills: They’ve been lavishly profiting from the opioid epidemic for nearly two decades. It’s also too early to tell how the opioid epidemic is affecting the livelihoods of men and women in their 20s and 40s. It may take years for us to fully comprehend the scope of its devastation. And there’s a good chance it’ll get worse before it gets better: In August, the FDA approved the use of OxyContin for children ages 11 to 16.
Courtesy of:


  1. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015 Dec 8;112(49):15078-83.


    This paper documents 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 reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. 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. We comment on potential economic causes and consequences of this deterioration.

  2. The overwhelming majority of people who survive an overdose of prescription opioids continue to be prescribed opioids afterward, often by the same prescriber, according to a new study.

    "We found the degree of continued prescribing both surprising and concerning," lead investigator Marc Larochelle, MD, MPH, from Boston Medical Center, in Massachusetts, told Medscape Medical News.

    Using the Optum national commercial insurance claims database, the researchers identified 2848 individuals aged 18 to 64 years who suffered a nonfatal opioid overdose while taking opioids for chronic noncancer pain. Digging deeper, they discovered that 91% of these patients (n = 2597) received one or more opioid prescriptions in the follow-up period after the overdose (median, 299 days).

    This is an "astonishing" finding, writes Jessica Gregg, MD, PhD, of Central City Concern, Portland, Oregon, in an editorial published with the study December 28 in Annals of Internal Medicine.

    The researchers also found that 212 patients (7%) suffered a repeat opioid overdose. At 2 years, the cumulative incidence of repeat overdose was 17% for patients receiving high doses of opioids (≥100 morphine-equivalent dosage) after the index overdose, 15% for those receiving moderate doses, 9% for those receiving low doses, and 8% for those receiving no opioids.

    Continued prescribing at high dosages was associated with a doubling of the risk of repeated overdose over 2 years of follow-up compared with discontinuing prescription opioids," Dr Larochelle told Medscape Medical News.

    The study also found that 70% of patients who continued to receive opioids after the overdose obtained them from a prescriber who had treated them before the overdose. However, after an overdose, the prescribed opioid dosages decreased to levels that were substantially lower than dosages received in the 3 months before the event, and dosages stabilized at those lower levels, the researchers report...

    In her editorial, Dr Gregg notes that prescribing guidelines state clearly that adverse events, such as overdose, are "compelling reasons to withdraw prescription opioids. Therefore, it is tempting, and it would be easy, to attribute these results to poor care, bad decisions, or sloppy prescribing. However, the problem goes well beyond individual prescribers' practices. These prescribing behaviors occur in a context in which substantial ― even deadly ― mistakes are inevitable."

    For instance, it is likely that many of the prescribers in the study did not know about their patients' overdoses, Dr Gregg notes, given that currently there are no widespread systems in place for notifying providers when overdoses occur. "Until such systems exist, providers will be left to act with dangerously limited knowledge. They will be unlikely to decrease or withdraw a patient's opioid prescription after an overdose if they have no knowledge that the event occurred," she writes.

    Prescribers need to know when their patients overdose, and they need sufficient knowledge and support to act on that information, Dr Gregg says. They need to know how to taper opioid dosages appropriately, how to use and prescribe buprenorphine (multiple brands), and what resources they can call on to help patients who insist on receiving opioids that their providers believe will do more harm than good...

    More people died from drug overdoses in the United States in 2014 than during any previous year on record, with increases in opioid overdose deaths being the driving factor, according to statistics released earlier this month by the US Centers for Disease Control and Prevention.

  3. The pain management clinic on Southern Boulevard in the Bronx, New York City, was called "the zoo" — a place where addicts, fake patients, and armed drug traffickers thronged, fought, and walked away with millions of oxycodone pills.

    The clinic's owner, Kevin Lowe, MD, did not write the bogus prescriptions himself but watched from afar with surveillance cameras as other physicians did his bidding: "[I]ll-equipped, desperate doctors in dire need of work," federal prosecutors said.

    A jury in May 2015 found the 55-year-old Dr Lowe guilty of one count of conspiring to distribute narcotics. Earlier this month, US District Judge Lorna Schofield, in the Southern District of New York, sentenced him to 144 months in prison. Prosecutors had sought an even stiffer sentence, arguing that "the magnitude of the defendant's conduct places him on par with true drug kingpins."...

    Dr Lowe owned and operated a string of clinics in New York City called AstraMed, but only the two clinics where Dr Terdiman and Dr Virey worked were involved in the pill-mill conspiracy, according to prosecutors.

    Court records describe a brazen criminal enterprise. Drug traffickers known as crew chiefs commanded fake patients, who paid $300 for an office visit lasting only a minute or two. There were no tests or physical examinations. Crew chiefs footed the bill and gave their fake patients nominal sums for their role. The fake patients obtained oxycodone prescriptions, had them filled, and turned over the pills to their crew chiefs, who sold them on the street for $30 apiece in New York City and for more elsewhere. Independent drug dealers and addicts lined up for prescriptions after paying admission fees as high as $1600 in cash.

    Practice management for this kind of clinic sometimes turned violent. Crew chiefs and their bouncers were not above throwing a wayward clinic patron through a window or an uncooperative employee against the wall. Prosecutors alleged that members of the conspiracy murdered at least two individuals who got in their way. Physicians were pressured — and in one instance threatened at gunpoint — to prescribe oxycodone at outrageously high volumes.

    The gangster-style persuasion appeared to work. Between January 2011 and February 2014, AstraMed physicians wrote nearly 35,000 unnecessary prescriptions for oxycodone, totaling some 5.5 million tablets. Their street value topped $165 million. During this period, Dr Lowe collected more than $7 million in cash for bogus office visits, prosecutors said.