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It’s not just opioids: ‘Diseases of despair’ claim a growing number of Minnesotan lives

While mortality rates for many causes of death in the United States have been in decline overall, mortality related to things like drugs, alcohol and suicide have been rising.

This month, the Minnesota Department of Health announced new data on drug overdose deaths. There were 637 such deaths in 2016, about five times the number of overdoses in 2000.

Those are alarming figures, and they have rightfully caught the attention of public health officials. But opioid-driven drug overdose deaths are not the only form of mortality on the rise in Minnesota.

“Minnesotans are suffering from what we’re calling diseases of despair, such as chronic pain and chemical dependency,” Minnesota Department of Health Commissioner Dr. Ed Ehlinger said in a press conference announcing the new numbers. “We see similar trends of increased rates of suicides and alcohol hospitalization across the state.”

“Diseases of despair” is a relatively new term, referring to things like drug and alcohol abuse, suicide — all increasingly common causes of death in the 21st century in the U.S. The term gained traction during the 2016 election, caught up in the dialogue about why now-President Donald Trump’s populist message appealed to working-class whites. Today, they’re some of the fastest-growing causes of death in Minnesota.

Drugs, alcohol and suicide

What, exactly, do officials mean by “diseases of despair”?

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“These diseases and outcomes are brought on in part by a lack of hope, a lack of opportunity and a lack of paths out of poverty,” according to Ehlinger.

Researchers say this despair is partly to account for the fact that, while mortality rates for many causes of death in the United States have been in decline overall, mortality related to things like drugs, alcohol and suicide have been rising.

Minnesota, a state in better than average health that occasionally bucks national trends, is no exception here.

Drug, alcohol and suicide mortality in Minnesota, 1999-2015
Rates are age-adjusted, which means they account for differences in the age of the population over time.
Source: Centers for Disease Control (drug and alcohol mortality rates) Minnesota Department of Health (suicide mortality rate)

Alcohol-related mortality rates reached 9.6 per 100,000 people in Minnesota in 2015, the most recent year of data available, following a steady rise since about 2007, compared to a national rate of 9.1 per 100,000 people, data from the Centers for Disease Control show (all mortality rates in this story are age-adjusted, which controls for the fact that some age groups are more likely to die of certain causes than others).

The CDC includes deaths that stem from alcohol dependence and other uses: accidental alcohol poisoning, injuries unintentionally and intentionally caused under the influence of alcohol, other indirect causes related to alcohol and fetal alcohol syndrome.

When it comes to suicide, Minnesota’s rates are also on the rise, from about 9 deaths per 100,000 people around 2000 to 13.1 per 100,000 people today. That’s on par with the national rate of 13.3. (Suicide attempts are also up at the national level, particularly among young, economically disadvantaged adults.)

And as for deaths stemming from drug abuse, they’re up, too, and have been for quite a while. In 2015, Minnesota’s drug-induced death rate was 11.7 deaths per 100,000 people, more than three times the rate of death by drugs in 1999.

Minnesota’s drug-induced death rate is lower than the U.S.’s as a whole, at 17.2 per 100,000 people, but the number of deaths at the hands of every drug category tracked by the Minnesota Department of Health — opioids, heroin, psychostimulants (including methamphetamine) and benzodiazepines — except cocaine, is up.

Overwhelmingly, and increasingly, opioid painkillers are responsible for overdose deaths. As their death toll has risen, they have captured the attention of politicians, medical professionals and media.

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Drug overdose deaths in Minnesota, 2000-2015
While the number of overdose deaths attributable to most categories of drugs has increased in Minnesota, opioid painkillers represent the biggest share of that increase.
Source: Minnesota Department of Health

These painkillers are often introduced to patients in doctors’ prescriptions, and because of that, there’s disagreement over the degree to which opioid deaths are attributable to socioeconomic factors, i.e. “despair.” Some researchers are adamant that patterns in opioid-related deaths are more closely related to the way the drugs are distributed and prescribed, that is to say, more in some areas than others.

But others believe a sense of hopelessness may be fueling higher rates of opioid addiction and death in some parts of the U.S. that are particularly hard-hit. Reports from places like Kentucky and West Virginia describe a changing economy that’s left working class people with worse jobs and a sense that they’re living in a land they don’t recognize. These places tend to have more people on disability and higher rates of opioid prescriptions.

In Minneota, opioid prescriptions are on the decline, but the drugs are still killing people all over the state.

Distribution of despair

These types of deaths have different causes, but they have one important thing in common: research has connected them to feelings of hopelessness.

Are Minnesotans feeling more hopeless than they once were? The research is still emerging to connect the way people are feeling to some of these increased mortalities, said Serena King, associate professor of psychology at Hamline University, but some experts make a case that an increasingly divided society and more widespread feelings of isolation may be contributing to the rise in diseases of despair.

“Even though we’re so connected on social media, we’re so disconnected to each other's human condition,” King said. “Because of that, we might feel more socially isolated, relatively speaking, as a generation or as a community.”

Addiction and depression are equal opportunity diseases, King said — they can happen to anyone. But it’s the places where people are potentially feeling the most disconnected where these diseases have really taken root, research suggests.

In “Deaths of Despair: from the Cities to the Hollers: Explaining Spatial Differences in U.S. Drug, Alcohol, and Suicide Mortality Rates,” Syracuse University associate sociology professor Shannon Monnat looks at the geographic distribution of mortality rates due to drugs, alcohol and suicide in economically disadvantaged parts of the U.S.

“In the places with high rates of drug, alcohol, and suicide mortality, economic distress has been building and social and family networks have been breaking down for several decades,” Monnat wrote in an email to MinnPost.

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“This is about downward mobility at the community level. In these places, there are now far fewer manual labor jobs that once provided livable wages and benefits to those without a college degree,” she wrote. “This isn’t new. It’s been building for at least the last three decades.”

It’s happening in Minnesota, too. Monnat found the highest rates of drug, alcohol and suicide deaths in Minnesota in parts of the Iron Range, where unemployment and poverty rates are some of the highest in the state, and in Cass and Mahnomen counties, home to American Indian communities, which are disproportionately affected by some of these issues.

When Ehlinger travels to meet with communities around the state, he hears concerns about these issues. “Some of the communities are in distress. ‘We don’t have hope and our teens don’t have anything to live for,’ Ehlinger said, explaining their worries.

Income inequality is another factor that seems to correlate with diseases of despair, Ehlinger said. Minnesota has some of the largest opportunity gaps between whites and people of color in the U.S. and also has stark differences in mortality rates for diseases of despair.

When it comes to drug mortality, rates for American Indians are six times higher than for whites (68.5 and 11.4 deaths per 100,000 people, respectively, in 2015), and rates for black Minnesotans are twice as high as whites, at 22.2 deaths per 100,000 people.

American Indians in Minnesota have the highest rate of alcohol mortality, at 53.5 per 100,000 people in 2015, followed by black Minnesotans, at about 9.9 per 100,000 people. White Minnesotans’ mortality rate due to alcohol was 9.5 per 100,000.

For communities of color, trauma caused by marginalizing policies and behaviors have affected generations, Ehlinger said. “The socioeconomic conditions in communities of color and American Indians — they’ve seen these things just eat away at the resilience of the community,” he said.

White Minnesotans have the highest suicide rates, (13.6 per 100,000 people compared to 9.4 for Asian and Pacific Islanders, and 7.4 for black Minnesotans), according to Minnesota Department of Health records.

Finding the key

At the Minnesota Department of Health, Ehlinger and his colleagues are proposing a mortality review looking at diseases of despair from a public health perspective. That means looking back at the circumstances of some of these deaths to get a handle on their true underlying causes. Hopefully, understanding cause and effect will be the key to getting those rates back down, Ehlinger said.

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A similar review of infant deaths which investigated why very young Minnesotans were dying found social and economic factors, some of which were alterable, at the root of many of these deaths. That helped officials pinpoint effective ways to intervene.

On diseases of despair, “We want to get more objective data (so) we can really make the case for investing in communities, investing in the common good,” Ehlinger said.