Suicide, opioids tied to ongoing fall in US life expectancy: Third year of drop
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* Julia Haskins

American life expectancy continues to decline, with high mortality rates largely fueled by suicide and drug overdoses — both growing public health crises that reflect deficiencies across many social determinants of health.

In November, the National Center for Health Statistics published data briefs on three critical trends in public health: Life expectancy in the U.S. declined to 78.6 years in 2017 from 78.7 in 2016. The rate of drug overdose deaths, largely driven by opioids, was 9.6 percent higher in 2017 than 2016, and 3.6 times the rate in 1999. And from 1999 to 2017, the rate of suicide increased 33 percent.

The findings were particularly alarming to the public health community because it is the third year in a row that U.S. life expectancy has dropped. Life expectancy among women remained the same in 2017, at 81.1 years, but in men fell from 76.2 years to 76.1 years.

Meanwhile, a study published in October in *The Lancet* found that American life expectancy is projected to increase 1.1 years to 79.8 in 2040, but the U.S. will drop in rank to 64th among 195 countries.

“Life expectancy gives us a snapshot of the nation’s overall health, and these sobering statistics are a wake-up call that we are losing too many Americans, too early and too often, to conditions that are preventable,” Centers for Disease Control and Prevention Director Robert Redfield, MD, said in a news release responding to the NCHS data.

Deaths from suicide and opioid overdose fall in the category of deaths of despair, which refer to breakdowns in social determinants of health that lead to mortality.

“There’s a reason why these conditions have been called conditions of despair, because I think they represent a disconnect between a kind of world that generates health and the kind of world (in which) most people live,” APHA member Sandro Galea, MD, DrPH, MPH, dean and professor at the Boston University School of Public Health, told *The Nation’s Health.*

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/49/1/1.2/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/49/1/1.2/F1)

Physician Laura Kehoe talks to a patient who is in treatment for a substance use disorder at Massachusettts General Hospital in Boston in April. More and better treatments for opioid addiction and suicidality can benefit U.S. life expectancy.

Photo by Craig Walker, courtesy The Boston Globe/Getty Images

An article published in December in APHA’s *American Journal of Public Health* illuminated just how deep the problem runs, with downturns in life expectancy and certain measures of well-being identified as early as 1980. Numerous factors can be attributed to declining life expectancy, according to the article, with failures in democratic institutions and regulations, economic stagnation and increasing medical costs cited.

Suicide and opioid addiction are not the same, with different causes and solutions. But as conditions of despair, both opioid addiction and suicidality are rooted in social and socio-economic adversities, many of which are widespread in the U.S.

“There are many communities in America where it is hard to find the road to economic opportunity, and we have observed escalating rates of economic inequality in our country that drive fundamental barriers to individual well-being that affect health,” Colleen Barry, PhD, MPH, chair of the Department of Health Policy and Management and professor at the Johns Hopkins Bloomberg School of Public Health, told *The Nation’s Health.* “Health and secure employment and secure housing are all inextricably linked. And to the extent that it is harder to make ends meet than it has been in many communities in America, that inevitably affects our health.”

Besides social and economic strife, the opioid crisis has been further exacerbated by misconduct in the pharmaceutical industry and dangerous prescribing practices for an extremely addictive class of drug, Barry said. According to the National Institute on Drug Abuse, pharmaceutical companies in the late 1990s minimized the addictiveness of prescription opioids for pain relief, leading health care providers to prescribe them more frequently.

Overdose deaths involving fentanyl, which is 50 to 100 times more potent than morphine, and other synthetic opioids have also skyrocketed. The overdose death rate involving synthetic opioids other than methadone jumped by almost half between 2016 and 2017, according to the NCHS data brief on drug overdose deaths.

“This is just an explosive combination, and we’ve seen the explosion in the form of this devastating epidemic that the country is facing right now,” Barry said.

The NCHS data point to regional differences in overdose deaths that align with trends in the national opioid crisis: West Virginia, Ohio, Pennsylvania and Washington, D.C., had the highest rates of drug overdose deaths in 2017.

## Suicide rates in US failing to decrease

Progress toward reducing suicide in the U.S. has been slow. It has remained the 10th-leading cause of death for all ages in the U.S. since 2008, according to the NCHS data brief on suicide mortality. Increases in suicide were documented among both men and women from 1999 to 2017, and rates of suicide were highest in the most rural U.S. counties.

Conditions such as breast cancer have had decreases in morbidity and mortality resulting in part from increasing awareness, better treatments and a wealth of research. But Julie Cerel, PhD, director of doctoral programs and professor at the University of Kentucky College of Social Work, said suicidality has not been embraced the same way.

“We’ve really struggled to have significant funding for suicide (research and prevention), and stigma has really gotten in the way of being able to talk about it openly and have conversations that can lead to changing of public health behaviors,” Cerel told *The Nation’s Health.*

Best practices for helping people with suicidality are also not being disseminated well enough, said Cerel, who is president of the American Association of Suicidology. There are multiple touchpoints for people struggling with suicidality throughout the health care sector, although they are in many cases untapped. She pointed to a study published in June in *AJPH*, which found that just 10 states as of October 2017 had mandated suicide prevention training for mental health professionals.

Many people who attempt suicide will end up in the emergency department, making it a critical point of contact.

A 2017 brief from the Agency for Healthcare Research and Quality found that from 2006 to 2014, the rate of emergency department visits related to mental health and substance misuse increased 44.1 percent, while visits for suicidal ideation soared by 414.6 percent. But the systems in place do not do enough to support people after they are released from emergency care, Cerel said.

Many Americans are touched by the epidemics of opioid addiction and suicide, either personally or through connections with others. But despite their pervasiveness, conditions of despair are often marked by secrecy and shame, preventing people from accessing care.

“One other really important piece that links suicide and addiction is stigma,” Barry said. “We have for both mental illness and substance use disorder extremely high levels of stigma in our society.”

Disdain toward people struggling with conditions of despair speaks to larger problems in the U.S. health care system, Galea said. With U.S. health care spending heavily invested in curative care, mental health has taken a backseat to treatment for physical illness, even though the former has higher rates of morbidity and mortality.

“We have not invested in treatment for common population mental illnesses like diseases of substance addiction and suicidality,” he said. “We have made it difficult for people to seek the help that they want.”

Such an attitude is especially problematic considering the links between opioid addiction and suicide. People who require treatment for suicidality may also need help with opioid addiction. While many deaths from opioid overdose are unintentional, research shows that both people who have chronic pain and take high doses of opioids are at an increased risk of suicide.

“We still have amazingly underfunded mental health care systems, and not a lot of…handoff between mental health and substance use, especially when they overlap,” Cerel said.

Overcoming stigma and building awareness can help normalize conditions of despair, enabling researchers and advocates to promote evidence-based solutions. And it is in the purview of public health to focus on solutions that have been shown to work, and without judgment toward people who are struggling.

And even with science guiding treatment and interventions, it is critical to keep social determinants of health — from housing to employment to family connections — at the forefront, while also recognizing the economic difficulties that drive conditions of despair, Barry said. As has been the case for the national opioid epidemic, without a public health perspective, people will continue to suffer.

“Unless we can fully embrace a public health approach to solving this problem, we’re going to continue seeing escalating death rates,” Barry said.

For more information on the briefs, “Mortality in the United States, 2017,” “Drug Overdose Deaths in the United States, 1999-2017” and “Suicide Mortality in the United States, 1999-2017,” visit [www.cdc.gov/nchs](http://www.cdc.gov/nchs).

*   Copyright The Nation’s Health, American Public Health Association