After more than a century of progressively increasing lifespan in the US, our longevity has begun to decline. According to the Centers for Disease Control and Prevention (CDC), the average lifespan in the US in 2017 was 78.6 years, down from 78.8 years in 2015. This is a considerable loss with broad and sweeping implications.
Why has this decline occurred? Suicide and opioid overdose deaths. The suicide death rate per 100,000 persons has been increasing since the turn of the century, particularly in the past decade. The rate now stands at 14.0 per 100,000 persons in 2017. Similarly, the opioid overdose death rate has been increasing, particularly in the past five years. It also now stands at 14.0 per 100,000 persons in 2017. Thus, suicide and opioid overdose deaths are a highly significant public health crisis in our country.
Considerable conjecture has occurred regarding intentionality in opioid overdose deaths. Many of these deaths take place without any message, note or other evidence. Absent such information, intentionality virtually is impossible to determine.
However, lack of this information should not deter our efforts to prevent needless deaths, whether due to suicide or opioid overdose and whether intentional or unintentional. In this commentary, I would like to argue that very similar causal chains are operative in these types of death. What will vary is the particular sequence of events that leads to early death.
Over the past 10 years, we have learned that the social determinants of health play a very large role in our health and wellbeing. The Great Recession and its reverberating effects have exerted a large influence on the risk of the so-called “diseases of despair”, i.e., deaths due to alcohol cirrhosis, opioid overdose or suicide. Thus, negative social determinants are a very significant trigger for the sequences described below.
The actual sequence leading to early death could start with one or more adverse experiences, such as personal financial stress, job stress or loss, interpersonal problems or loss, or other difficulties. These personal difficulties could lead to depression or anxiety, followed by prescription opioid use to control pain, followed by suicide or opioid overdose death. Or the sequence could start with adverse experiences followed by prescription opioid use, followed by secondary depression, followed by suicide or opioid overdose death. Or the sequence could start with pain followed by the other causal factors.
What is most important to realize is that these adverse health factors are all mutually reinforcing. For example, depression multiplies the probability that a person will use opioids, and vice versa. Both factors increase the probability of a suicide or opioid overdose death.
Recognition and treatment are critical for depression or anxiety and opioid dependence or addiction. Fortunately, we have proven procedures to accomplish both, including cognitive behavioral treatment (CBT) for depression or anxiety and medication-assisted treatment for opioid addiction.
But we also must go further up the causal chain.
At the social determinants level, community level interventions are needed in which a community comes together for collective action. All sectors—public, private, and nonprofit—must step forward. The effort should focus on identifying the specific problems in that community—loss of jobs, lack of housing, social isolation of the elderly, centrifugal spaces, etc.—and then initiating collective action. US Surgeon General Jerome Adams, MD, MPH, calls this the “creation of healthy and prosperous communities.” Obviously, the goal will be to reduce the propensity of negative social determinants to trigger the sequences that lead to suicide or opioid overdose deaths.
At the personal level, interventions are needed to prevent the initiation of the sequences leading to early death. The principle “if you see something, do something” applies. This may be family member to family member, worker to coworker, teacher to student, neighbor to neighbor, provider to client, or other relationship. The important point is to intervene as early as possible to develop the needed support and care.
Considerable progress currently is being made in predictive analytics, i.e., the use of quantitative data to predict some future event or state. This includes work to predict who is likely to have a future opioid overdose. We need to accelerate this work and extend it to likelihood of a suicide attempt.
I simply have scratched the surface of a huge national problem here. To put the consequences in perspective, we are losing the equivalent of the entire population of a city like Burbank, California, Greeley, Colorado, or South Bend, Indiana, each year to suicide and opioid overdose deaths. To say the least, that fact is frightening. Our best thought and action are required.