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Declining US life expectancy is driven by more than just opioids, study finds

BMJ 2019; 367 doi: (Published 29 November 2019) Cite this as: BMJ 2019;367:l6753
  1. Owen Dyer
  1. Montreal

The United States began to fall behind other rich countries in improving life expectancy long before the opioid epidemic gathered steam around the turn of the millennium, says an analysis published in JAMA,1 and opioid deaths are just one of several factors contributing to increased mortality among US people of working age.

The country has matched other wealthy nations in cutting its death toll from big killers such as cancer, ischaemic heart disease, and AIDS, but these gains have been undermined by an increasing toll from drug overdose, suicide, liver disease, and lung diseases, the study finds.

“There has been an increase in death rates among working age Americans,” the lead author, Steven Woolf, told ABC News. “This is an emergent crisis, and it is a uniquely American problem since it is not seen in other countries. Something about life in America is responsible.”

Class and regional differences

The retrogression in US life expectancy is driven entirely by higher death rates in the country’s working age population. Mortality rates continue to decline among children under 14 and adults over 65—two groups, the study authors noted, whose healthcare expenses are mostly publicly covered.

Class and regional differences in the US have widened, and the burden of increasing mortality falls most heavily in rural districts, in conservative states, and on people without a college education. Life expectancy continues to rise in big cities and on the west coast.

The JAMA study has drawn intense media coverage, being the latest research to support a widespread narrative that “diseases of despair” are undermining decades of health gains.

Many headlines focused on the study’s reference to three straight years of declining US average life expectancy during 2014-17: in fact, that was not a finding of this study nor a new finding. The 2017 figure was released last December by the Centers for Disease Control and Prevention.2 Next month it should release the 2018 figure, showing whether life expectancy has fallen four years in a row.

Midlife mortality

The role played by deaths from opioid overdoses is undoubtedly huge. Life expectancy has fallen most quickly since 2010 in states most associated with that epidemic: West Virginia and New Hampshire saw the greatest rises in midlife (age 25-64) mortality, up 23% since 2010. And mortality in the 25-34 age group has increased 29% nationwide since 2010, largely driven by opioid overdoses.

But the problem of declining life expectancy goes beyond the opioid epidemic and predates it, the study found. Fatal midlife drug overdoses among women have risen 486% this century, but among white women respiratory disease mortality was a larger contributor to changes in life expectancy than either suicides or alcohol related causes, accounting for more deaths in rural areas than drug overdose.

This echoes the tobacco industry’s increased marketing focus on women in the 1980s, the authors suggested, noting that the growth in obesity related diseases also dated back to that period.

Many of the mortality trends driving life expectancy downwards date from the 1980s, the analysis found, but only in the past few years have they come to outweigh the gains made in treating heart disease and cancer. So, while overall life expectancy in the US has been falling for only three years, the country’s annual gains in life expectancy began to fall behind other rich nations nearly four decades ago. When opioid deaths began to soar in the late 1990s, US life expectancy was already below the average in Organisation for Economic Cooperation and Development countries.

“Any theory for decreasing US life expectancy must explain why this trend is less pronounced in other industrialised countries,” the authors said. These differences, and the characteristics of high and low mortality regions in the US, point towards a socioeconomic explanation, they argued.

“It’s possible to blame some of this on the opioid epidemic,” said Woolf, of Virginia Commonwealth University. “But it isn’t lost on us that these are the regions of the country that have been hit so hard by the economy.

“Families and communities have been dealing with many years of economic strain. That strain itself could affect health in ways that don’t have to be limited to despair or unhealthy behaviours.”


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