Deaths of Despair
With an epidemic of opioid abuse, the generation that never wanted to grow old is dying ahead of its time
Pain, opiates and what you need to know now
MIDDLE-AGED WHITE PEOPLE are not usually anyone’s idea of a vulnerable population, even in an era that aims for diversity. Having been history’s conquerors and kings, they remain symbols of the establishment, its presidents and chief executives, comfortable, and still powerful.
But in the fall of 2015, two Princeton University economists dropped a bombshell on that assumption. Angus Deaton, who had just won a Nobel Prize in economics, and Anne Case reported in the Proceedings of the National Academy of Sciences that the death rates of middle-aged whites in the U.S. had jumped sharply. For the first time in decades, the life expectancy of white men and women between the ages of 45 and 54 had plummeted – a trend not seen in any other rich country.
Between 1999 and 2013, the study found mortality rates of every other age and ethnic group in the U.S. fell by a steady clip of about two per cent per year. But among middle-aged whites, the mortality rate had risen by half a per cent per year. If it had continued to decline at the same rate as it had before 1998, an estimated 488,500 lives would have been saved. Or, as Deaton told the Washington Post, “Half a million people are dead who should not be dead.”
The news hit like a sucker punch. Life expectancy is considered the yardstick of humanity’s well-being, the sacred gauge of social progress. So what did it say when, despite advances in health care and nutrition, tens of thousands of white middle-aged Americans
had died years before their time? And what did it say when the cause of these premature deaths was not cancer or heart disease, or any of the common killers we know, but rather those we didn’t realize we knew so well – drug poisonings, suicides, alcohol-related liver diseases. “Deaths of despair,” the researchers called them.
In essence, the study concluded that a quiet epidemic of substance abuse and hopelessness is plaguing America’s baby boomers, that the generation that never wanted to grow old is indeed dying younger – and in far greater numbers – than anyone predicted.
“Those currently in mid-life may be a ‘lost generation,’” Deaton and Case wrote, noting that “if the epidemic is brought under control, its survivors may have a healthy old age.” But, they warned, addictions are hard to treat.
A perfect storm
It may be tempting to blame all this distress on the recent recession. But the spike in mid-life mortality predates the 2008 financial crisis by a decade. Still, baby boomers are a sandwiched generation, financially pinned between the extra costs of caring for elderly parents and putting kids through university – often, while retirement shrinks their incomes.
“Many of the baby-boom generation are the first to find, in mid-life, that they will not be better off than were their parents,” Case and Deaton wrote, especially among those with only a high school education.
While people with the least education had the highest death rates, the study did find drug poisonings and suicides increasing among middle-aged whites of all education levels – a trend that doesn’t stop at the border. Overdoses and suicides among baby boomers have also been rising in Canada.
In 2011, more middle-aged Canadian men – 1,366 – died by suicide than by motor vehicle accidents, homicide and HIV combined, according to the Canadian Association for Suicide Prevention. Meanwhile, a recent study from the Canadian Institutes of Health Information and the Canadian Centre on Substance Abuse reports that opioid poisonings are putting 13 people a day in hospital – a jump of more than 30 per cent between 2007–08 and 2014–15 – and most of them are age 65 and older.
The Province of Ontario has tracked 2,383 opioid-related deaths between 2006-2010. But without a national system to track drug-related fatalities (different provinces use different methods), there’s no concrete numbers available and no way to know if all this is also bringing down life expectancy for middle-aged Canadians.
“At this point, there is no measureable impact on life expectancy,” says Dr. Benedikt Fischer, a senior scientist at the Centre for Addiction and Mental Health in Toronto. But, Fischer adds, “this doesn’t mean there is no impact and with rising opioid death rates, this impact will increase.”
What is clear is that North America’s baby boomers have found themselves in a perfect storm of selfdestruction. For starters, boomers happened to reach the age of aches and pains just as highly addictive prescription opioid painkillers went mass market in the 1990s. And many not only became dependent on these dangerous meds to treat bad backs or cranky knees, but the angst aging can bring.
“They’re losing their jobs, either because they are being phased out or they are retiring but, with that, they are losing … prestige, social status and the sense of identity and self-esteem that comes with that,” says Dennis Long, executive director of Breakaway Addiction Services in Toronto. “There’s only so much golf you can play, and then it gets a bit thin.”
At the same time, as aging takes its physical toll “stuff starts to break down … and with all this comes an existential pain. The idea of a mid- or late mid-life crisis is not a myth. People look around and say, ‘I wanted to do so much more in my life. I thought I’d do so much more.’”
In response, many have made their youthful drug habits a crutch in middle age – and beyond.
At Breakaway, where Long, 68, has worked for more than 25 years, it used to be that the community of drug users was well known to staff and to each other. But now there’s a growing number of newcomers: middle-class, middle-aged professionals, still working or recently retired. “I don’t think it’s a blip. I think we’ve crossed over a certain line with opiate use, and it’s trending in the wrong direction.”
The 2012 U.S. National Survey on Drug Use and Health estimates that by 2020, close to six million adults over age 50 will need drug or alcohol rehab, nearly double the number of over-50s seeking treatment in 2002. In New York City, that future has already arrived: a recent New York University study found people over age 50 accounted for close to 50 per cent of people in opioid rehab in 2012, up from 7.8 per cent in 1996.
The growing demand has already heralded the rise of boomer-tailored treatment programs. Online, one South Florida facility, even makes its Rehab for Boomers pitch in a groovy ’60s-styled ad that reads: “When one considers the permissive attitudes toward drug use that arose during the coming of age of most baby boomers, it’s no surprise that many of them find the need to check into drug and alcohol rehab even in their later years.”
The big difference, says Long, is that baby boomers “grew up in the ’60s, when drug use was common and not very scary.” But today, those harmless highs of youth have run smack into North America’s deadly opioid crisis, a public health disaster of such epic
proportions that it’s been dubbed “the worst man-made epidemic in modern medical history.”
A man-made epidemic
Opioid medications, the heavy-duty class of narcotic pain relievers that includes morphine, oxycodone and hydrocodone, were once considered so potent and potentially addictive they were reserved only for the dying, and those in extreme pain. But in the 1990s, after some research suggested the meds could be used more broadly, drug firms designed new slowrelease versions and launched a marketing crusade to convince doctors they could be safely prescribed, with low risk of addiction, for long-term use. And doctors did prescribe them – with abandon.
They dished them out for everything from toothaches to tennis elbow, Percocet, Vicodin, OxyContin, the billion-dollar blockbuster that became known as “Hillbilly Heroin.” Prescriptions in Canada and the U.S. multiplied to record highs – and so did the number of people addicted to them and killed by them.
Writing in the Globe and Mail last August, David Juurlink, head of clinical pharmacology and toxicology at the University of Toronto, penned a lament for “the hundreds of thousands dead, the uncountable millions harmed” saying, “Despite the best of intentions, we flooded North American homes with opioids purer and often stronger than heroin … Many – by some estimates, 10 per cent – spiralled into addiction, even though we had been told this would happen only rarely. Some crashed their cars. Others fell, fracturing bones or sustaining head injuries. And some, especially those prescribed high doses or who took their meds with a sedative or alcohol, simply went to sleep and didn’t wake up.”
(In the U.S., the Connecticut company that developed OxyContin, Purdue Pharma LP, pled guilty in 2007 to a criminal charge of misleading doctors and consumers about the drug’s potential for addiction and abuse. It paid more than $600 million in fines.)
More than 165,000 people have died since 1999 from prescription opioid overdoses in the U.S. and an estimated 78 Americans continue to die each day. But with the exception of Prince and Heath Ledger, most have died quietly, while some 650,000 opioid prescriptions are still dispensed daily, according to the U.S. Department of Health and Human Services.
Experts suspect the scope of the crisis in Canada – which is second only to the U.S. in its consumption of opioid drugs – may be just as shocking. And with the Canadian Centre for Addictions reporting a 203 per cent rise in usage between 2000 and 2010, the increase in Canadian consumption is even larger than that of the U.S. Says Fischer, “We are a global leader in this mess.”
And this mess has not occurred “in the usual marginalized groups where we typically see these things happen,” he adds, but in the middle-aged and white.
Exactly why the opioid crisis has hit whites hardest is a matter of ongoing research, speculation and controversy. But there are suggestions that blacks and minorities are less likely to have insurance policies that cover the costs of these drugs and that blacks and minorities may generally be more reluctant to take opioid painkillers. But other research points to racial bias and stereotyping among doctors.
Last August, Boston University researchers reported that black patients are about half as likely as whites to receive opioid medications in U.S. emergency departments despite having the same levels of pain. The conclusion was based on reports from more than 60 million emergency department visits between 2007 and 2011 among adults aged 18 to 65. The researchers said prescribing doctors may not empathize with the pain of their black patients, or they assume that blacks are more likely to be addicts and abuse the drugs.
A study published in April found “a substantial number of white medical students and residents hold false beliefs about the biological differences” between blacks and white (assuming, for example, that blacks have thicker skin or blood that coagulates more quickly), which may also affect how they treat pain in black patients.
As it is, Fischer believes what’s made white baby boomers susceptible to opioid addiction is simply “their exposure to it” with too many prescriptions, and many written at doses too high, for too long. “The prescription pad was the original source for many.”
Many deaths have occurred when someone with a legitimate prescription to treat pain takes an opioid and alcohol, or “maybe a Valium to sleep,” says Fischer, “both behaviours typical in middle class … and you don’t have to drink a lot for this to happen.”
(The recent study on opioid-related hospitalizations in Canada found nearly half of all cases are accidental.)
“MY LIFE WAS GETTING RUINED. I WAS FORGETTING THINGS. I THINK I WAS ABOUT 60 THEN”
“People are not seeing themselves as using drugs or thinking that this is a drug with risks. They think they are doing something medical,” Fischer says. “If you ask people, ‘What’s worse, a joint or a Percocet?’ most people would say the pot. But in view of everything that we know, that is not categorically true.”
Uncomfortably numbGina, a client at Breakaway Addiction Services, was teaching music at a Montessori school when her doctor first wrote her a prescription for Percocet. She was in her late 50s and had twisted her ankle and torn the meniscus in her left knee. She had never taken the drug before, and at first, she says, “I took the drug only as it was prescribed.” But it was prescribed for five years. What happened next is foggy. “Crossing that line from pain to no pain, you get used to the way you feel when you take it, half there, hazy,” she says. “It just numbs and puts you out of touch with the world. I liked being half there.”
Instead of taking the drugs one at a time, Gina started taking them all at once – 12 a day.
“My life was getting ruined. I was forgetting things, dates, and I was still working, still teaching piano, and sometimes I’d fall asleep at the piano. I was losing my students. I think I was about 60 then,” she says.
It was Gina’s daughter who persuaded her to stop and seek treatment. “I didn’t like what it was doing to my relationship with my daughter,” Gina says, and that has been her incentive to recover, which, for more than two years, she has been trying to do.
Overcoming opioid addiction demands a long-term commitment, Long says, “it’s not like throwing away the cigarettes one day and saying, ‘I never went back.’ With this, there’s a relapse rate of 90 per cent if a person only stays [in treatment] for a year.”
In many cases, those first introduced to opioids by prescription end up turning to the dodgy and deadly
IN STUDIES, ASKED HOW THEY HANDLE EMOTIONAL DISTRESS, MEN SAY, “I’LL DRINK MORE”
substitutes the street has to offer, including heroin and fentanyl, the synthetic opioid that can be up to 100 times more potent than morphine.
After OxyContin’s makers introduced a tamper-resistant form of the drug in 2010 to discourage its users from crushing it to consume its full narcotic effects in one go, the change had an unintended consequence of driving some of those who became dependent to the illegal market, says Dr. Matthew Young, senior policy analyst at the Canadian Centre on Substance Abuse.
“Where there’s demand, organized crime will supply,” says Young, ““and they did – counterfeit OxyContin containing fentanyl and other ingredients. This is when the danger really spiked because at least with prescription-grade Oxys, there was quality assurance in that you know what you are taking. But now, with this … people don’t know what they’re taking … It could be fentanyl powered in with talc in a cement mixer rented from Home Depot.”
So, Young explained, someone who can no longer convince a doctor to fill a prescription might turn to a friend who has a couple of extra pills from who knows where, “and so it starts – and it’s not necessarily happening in an alleyway, it’s happening in middle-class homes. Some people regard it as a moral failure, but everyone wants to feel better, so before they took one, and now they take two.”
And with opioids, Young says, the physical pain goes away but along with that relief comes some euphoria and relief from mental pain. This doesn’t last long and wears off as tolerance to the drug develops. For some people, the euphoria is so powerful they seek to repeat the experience, but require higher doses and methods, such as crushing or snorting, to get the same result. Thus begins the cycle of dependency.
Boomers’ gloom
Mood-altering chemicals have always been a hallmark of baby boomers, and not just in their youth. With high rates of depression, boomers in their primes helped to make Prozac a household name. In 2008, the Pew Research Center, which tracks social trends, gave boomers a new nick name, “the gloomiest generation,” after finding that in mid-life they are more downbeat about their lives than adults who are younger or older.
Even still, Dr. Dan Bilsker, a clinical psychologist at the University of British Columbia, did not expect to see such a prevalence of this despair in mid-life – even among men, who commit about 80 per cent of suicides.
Among men, suicides had been like bookends, Bilsker says, high in the 20s, dropping by age 30 and then rising again after age 80, in life’s latter years. Mid-life was the calm. But while researching a project on men’s health, Bilsker discovered that suicides among men in Canada were peaking at around age 55 – “I thought what’s going on here?” He published his disturbing finding in 2011, a trend that had also been documented in the U.S. But there’s still little research exploring the forces driving this mid-life despair among men, Bilsker says, “and these are not small numbers, this is big data. It should ring every alarm bell in town.”
As it is, speculation abounds for the rise in suicides, theories that centre on “cut-throat capitalism” that swallowed retirement savings, a rising digital economy that’s displacing many in the workplace or an alleged lack of resilience in a generation that never had to face major adversity – as in no world war or Great Depression.
Bilsker calls all this the “hypothesis generation stage,” as society bats around theories to figure out the root causes of a generation’s despair. Though certain factors, he agrees, seem obvious: losing a challenging job to retirement, parents losing their role as children move on and feeling generally sidelined in life. These are all devastating things, he says, which can be “exquisitely painful.”
But whatever the causes, Bilsker says, it comes down to how individuals establish meaning in their lives. “If they feel like a failure, they get on a dangerous loop telling themselves that they let everyone down … ‘I let my family down, I expected so much more from myself.’ Ideas of suicide form, ideas of an escape – the pain is unbearable, not just physical pain but psychological.”
Men, meanwhile, don’t tend to deal with this pain constructively, Bilsker says. “In studies, men asked how they handle emotional distress say, ‘I’ll drink more.’”
If there is a silver lining to the disturbing trends of despair and early death among North America’s middle-aged, it could be that the generation that spawned an industry of self-help may be more likely to get help.
“They are more comfortable seeking treatment and talking to people about themselves and getting their heads around the fact that they have a problem,” says Long. “They’re way better than the silent generation of their parents.”