Which Came First, the Opioids or the Despair?

Middle-aged white Americans are dying at alarming rates. But there's reason for hope.

Dark days in America.

Photographer: Spencer Platt/Getty Images

Anne Case and Angus Deaton's 2015 article on rising mortality among middle-aged white Americans -- and the 2017 follow-up that attributed this rise to an increase in suicides, drug overdoses and alcohol-related deaths among those without college educations -- was among those rare academic papers that changed public debate. "Deaths of despair," the name that the wife-and-husband team of Princeton University economists gave the phenomenon, entered the popular lexicon, and their economic explanation for these deaths resonated:

We propose a preliminary but plausible story in which cumulative disadvantage from one birth cohort to the next -- in the labor market, in marriage and child outcomes, and in health -- is triggered by progressively worsening labor market opportunities at the time of entry for whites with low levels of education.

Blockbuster findings like this inevitably generate a lot of questioning and re-examination, and the Case-Deaton results have certainly done that. A big team of epidemiologists, most from the National Cancer Institute, examined death-certificate data and found results similar to Case and Deaton's but with some key differences: Drug overdoses were a much bigger cause of increased mortality than suicides or alcohol, mortality increases weren't restricted to the middle-aged, and American Indians and Alaska natives have seen even bigger mortality increases than whites. Columbia University statistics professor Andrew Gelman and political scientist Jonathan Auerbach sliced the age data more finely and found that much of the increase in mortality rates among 45-to-54-year-old whites was due to a shift in the composition of that age cohort, which as the last of the baby boomers aged into their 50s began to skew heavily toward the older end -- although even in their adjusted version the middle-aged white mortality rate hasn't declined as it has for other groups in and outside of the U.S. And in a study out this summer that hasn't gotten much attention yet, University of Colorado sociologists/demographers Ryan K. Masters, Andrea M. Tilstra and Daniel H. Simon also adjust more precisely for age and find that while suicide and alcohol-related death rates haven't gone up much, drug overdoses really have.

QuickTake Heroin and Opioids

None of these studies have refuted the key finding of the Case-Deaton research, which is that something disturbing is going on with the mortality rates of middle-aged white Americans. But they do seem to be shifting the explanation away from an economic one to something more epidemiological. The really big driver of the mortality shift is the opioid epidemic, and many of these opioid overdoses may not be the direct result of economic troubles. They're not really "deaths of despair." As Deaton himself put it in a March interview with the Atlantic's Annie Lowrey:

People who die of opioid overdoses are not trying to kill themselves. It really is this business where if you relapse, you die. And that’s not true for alcohol or other things.

Scott Winship and his team at Utah U.S. Senator Mike Lee's Social Capital Project have been compiling data on opioid-related deaths and economic and social indicators at the county level, with plans to publish a paper on the correlations this fall. In the meantime, they've published an assortment of animated maps of overdose rates, and it's striking how different things look from state to state. In New York, it's the New York City exurbs that have been hardest hit; in California, it's rural mountain counties far from any big city; in Ohio, it's everywhere. These seem to be patterns that can be better explained by peer effects and the shape of drug-distribution networks than by underlying economic conditions. That is to say, this may be at least as much a supply-side phenomenon as a demand-side one.

The two biggest supply-side factors, journalist Sam Quinones writes in his acclaimed book "Dreamland," were the 1996 introduction by Connecticut-based Purdue Pharma LP of the controlled-release prescription opioid painkiller OxyContin and the eastward spread in the late 1990s of the remarkable, decentralized "Xalisco Boys" distribution network of black-tar heroin from a small county on Mexico's Pacific coast. 1 In both cases, aggressive marketing campaigns (with other pharma companies and drug traffickers doing their part, too) pushed more people to try the drugs and get hooked on them. Then, according to a recent paper by three University of Notre Dame economists, a 2010 reformulation of OxyContin intended to render it less addictive drove users to try heroin, leading to even more overdoses.

There are emerging signs that the spread of these opioids/opiates 2 may have had significant economic implications. In a new version of a paper on declining labor-force participation (I discussed an earlier draft last year), Princeton University economist Alan Krueger writes that:

Evidence presented here suggests that much of the regional variation in opioid prescription rates across the U.S. is due to differences in medical practices, rather than varying health conditions that generate pain. Furthermore, labor force participation is lower and fell more in the 2000s in areas of the U.S. that have a higher volume of opioid medication prescribed per capita than in other areas. Although some obvious suspects can be ruled out -- for example, areas with high opioid prescription rates do not appear to be only masking historical manufacturing strongholds that subsequently fell on hard times -- it is unclear whether other factors underlying low labor force participation could have caused the high prescription rates of opioids in certain counties. Regardless of the direction of causality, the opioid crisis and depressed labor force participation are now intertwined in many parts of the U.S.

That drugs may have caused all this misery is so, so tragic. But it also offers some reason for hope, as drug epidemics do eventually tend to wane. My fellow Bloomberg View columnist Stephen Mihm has described the 19th-century opiate-addiction crisis in the U.S. that faded as the medical profession became fully aware of the dangers of prescribing morphine and the like. Opioid prescriptions are already on the decline -- although, as already noted, the ready availability of illegal substitutes has so far kept overdose deaths rising. It won't be easy, and it will take a while, but this will pass.

This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

  1. Disclosure: I haven't read the book yet! But, having read multiple reviews, and a New York Times essay by Quinones, I think I am able to summarize it. Still, planning to read it soon.

  2. Originally "opiates" were drugs actually derived from opium, while "opioids" were synthetic variants, but the terms seem to be used interchangeably these days.

To contact the author of this story:
Justin Fox at

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Brooke Sample at

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