In 2015, Princeton University economists Anne Case, Ph.D., and Angus Deaton, Ph.D., reported something unexpected. After decreasing since the end of World War II, rates of death began to increase in the United States for people in some groups. The rise in deaths was driven primarily by drug and alcohol overdoses, suicides, and liver disease. These conditions, in turn, were related to declining quality of life—reduced physical and mental health, increases in chronic pain, financial difficulties, and serious mental illness. Given the nature of these deaths, Drs. Case and Deaton referred to them as “deaths of despair.” They reported that the increase in mortality occurred primarily among 45-54-year-old non-Hispanic, White men and women.
A subsequent study led by researchers at Virginia Commonwealth University found an increase in deaths of despair among people ages 25–64 in a variety of groups, including non-Hispanic Whites, non-Hispanic American Indians and Alaskan Natives, non-Hispanic Blacks, Hispanics, and non-Hispanic Asians and Pacific Islanders. Although drug overdoses, alcohol-associated liver disease (AALD), and suicides played major roles in these increases, deaths also increased for falls and other injuries, heart disease, respiratory conditions, cancers, and other causes. And it appears that the United States is not alone, as deaths of despair are on the rise among middle-aged men and women in England, too.
Alcohol plays a prominent role in deaths of despair, contributing to overdoses, suicides, and liver disease, as well as to a broad range of other disease states that lead to mortality. Alcohol use is increasing among middle-aged adults in the United States and is more common when people are faced with stressful circumstances, such as job loss, divorce, economic downturns, chronic pain, or psychiatric conditions—all factors related to deaths of despair.
“I consider alcohol the elephant in the room when it comes to the mortality trends revealed in these recent studies,” says George F. Koob, Ph.D., Director, National Institute on Alcohol Abuse and Alcoholism (NIAAA). “People are more likely to drink excessively to help cope with significant challenges of life, but this is a slippery slope that commonly leads to more pain and misery.”
A significant contributor to deaths of despair, drug overdose deaths in the United States increased from 16,849 in 1999 to 70,237 in 2017. The largest increase involved opioids, which claimed nearly 400,000 lives during that period. Alcohol plays a role in about 1 in 5 overdose deaths involving opioids. Alcohol and opioid misuse share common underlying risk factors related to deaths of despair, including mood disorders, suicidal ideation, a history of trauma, and chronic pain. (For more information, see this story in NIAAA Spectrum “The Complex Relationship Between Alcohol and Pain.”) A recent study revealed just how dangerous the combination of opioids and alcohol can be. Both alcohol and opioids can cause death by suppressing areas near the base of the brain that control breathing. When researchers gave healthy younger and older adults 20 mg of oxycodone, breathing was reduced by 28 percent. Whey they combined this dose of oxycodone with enough alcohol to raise subjects’ blood alcohol concentration (BAC) to 0.1 percent—comparable to having about 4 drinks for women or 5 for men in an hour—breathing decreased by another 19 percent. The impact was bigger in older drinkers. Alcohol contributes to other drug overdoses as well. Deaths due to overdoses on benzodiazepines, medications often used to treat anxiety, have increased in recent years, and alcohol contributes to roughly 1 in 5 such deaths.
Drs. Case and Deaton reported that deaths from liver disease are key contributors to the increase in deaths of despair. The liver—the largest organ in the body—helps digest food, store energy, and detoxify alcohol and other harmful substances. The number of deaths in the United States each year from diseases of the liver is rising and reached 41,743 in 2017. Roughly half of these deaths were caused by AALD, particularly cirrhosis. Deaths due to AALD are more common in adults over the age of 45 than in younger drinkers, but the biggest increases in such deaths in recent years occurred among young adults ages 25–34.
Rates of suicide in the United States are increasing and are higher now than at any time since World War II. More than 47,000 people died from suicide in 2017, and suicide is the fourth-leading cause of death for people ages 35–54.
Alcohol misuse both follows and contributes to mental health conditions that increase the risk of suicide. People with AUD are twice as likely as those without AUD to experience major depression, five times as likely to suffer from bipolar disorder, and three times as likely to experience post-traumatic stress disorder. People with AUD are much more likely to contemplate suicide, and alcohol often plays a role in suicide attempts. Estimates suggest that nearly 1 in 4 males and 1 in 5 females are intoxicated—with BAC levels of 0.08 percent or more—at the time of a suicide.
In addition to overdoses, liver disease, and suicides, alcohol contributes to mortality in other ways that might add to deaths of despair. Alcohol plays a role in roughly 3.5 percent of all cancer deaths in the United States. For women, the risk of breast cancer increases with less than 1 drink per day. Compared to women who consumed fewer than 60 drinks in a typical year, those consuming 60–229 drinks (about 0.6 drinks per day, on average) were 20 percent more likely to develop breast cancer. Research also has shown that people who drink excessively have a greater risk of cancers of the mouth, esophagus, larynx, pharynx, liver, colon, and rectum.
Alcohol also is a common factor in deaths from injuries. The U.S. Centers for Disease Control and Prevention (2013) estimates that alcohol contributes to 32 percent of deaths from falls, 42 percent of deaths from fires, 47 percent of deaths from homicides, and 34 percent of deaths from drownings.
Alcohol is not the only factor driving the increase in deaths of despair, but raising awareness of the health risks posed by alcohol and the dangers of using alcohol to cope with challenges in life could help reduce the number of such deaths.
According to Dr. Koob, “Perhaps our most fundamental responsibility is to ensure that all people possess basic knowledge of alcohol’s immediate and long-term health effects, and that all healthcare professionals, from trainees through senior clinicians, make alcohol assessment an integral part of every interaction with patients.” Currently, 85 percent of adults ages 18 and older in the United States see a doctor or other healthcare professional each year, but fewer than 1 in 4 reports being asked during a visit in the past year how often or how much they drink.
To learn more about the health risks posed by alcohol and to evaluate whether your relationship with alcohol might constitute AUD, please visit the NIAAA website, Rethinking Drinking. To explore treatment options and to locate a treatment provider, please visit the NIAAA Alcohol Treatment Navigator.
Centers for Disease Control and Prevention. Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI). Average for United States 2006–2010 Alcohol-Attributable Deaths Due to Excessive Alcohol Use. https://go.usa.gov/xym4p. Accessed July 15, 2019.
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