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Opioid ‘Deaths of Despair’ Don’t Explain Mortality Gap

MedicalResearch.com Interview with:

Arline T. Geronimus Sc.D Professor, Health Behavior and Health Education School of Public Health Research Professor Population Studies Center Institute for Social Research University of Michigan Member, National Academy of Medicine

Dr. Geronimus

Arline T. Geronimus Sc.D
Professor, Health Behavior and Health Education
School of Public Health
Research Professor
Population Studies Center
Institute for Social Research
University of Michigan
Member, National Academy of Medicine 

MedicalResearch.com: What is the background for this study?

Response: The gap in life expectancy between less and more educated Americans grew over the last 30 years, a deeply troubling fact. We are alone among western nations in these trends. We aimed to determine what causes of death account for this growing educational gap in life expectancy and whether the gap has continued to grow in the most recent years.

Disturbingly, we found the educational gap in life expectancy has continued to grow.

Why? A common theory is that this growing inequality is due to the opioid epidemic. Some even speculate that the less educated are dying from a composite of what they call “deaths of despair” – opioid and other drug overdose, suicide and alcoholic liver disease – with the theory being that as less educated and working class Americans have faced job loss and stagnating wages, they experience hopelessness and despair and turn to drugs, alcohol, or even suicide to ease or end their pain and feelings of hopelessness.

However, while opioid, suicide and alcoholic liver disease deaths have increased among white youth and young adults and is cause for concern, this does not imply that these deaths should be grouped together as “deaths of despair” (DOD) or that they explain the growing educational gaps in life expectancy across all groups – men, women, whites, blacks, or older as well as younger adults.

MedicalResearch.com: What are the main findings?

Response: Using census and Vital Statistics data, we applied life-table methods to calculate cause-specific years of life lost between ages 25 and 84 by sex and educational rank for non-Hispanic blacks and whites in 1990 and 2015. We found only a small share of the growth in the educational gap in YLL occured among 25-64 year-olds, with the lion’s share occurring at ages 65 to 84 years. Opioid and other drug deaths were an important part of the growing inequity among white Americans, especially white men, but not for black Americans. Growth in inequities due to deaths attributed to cardiovascular diseases, cancers and other internal causes accounted for substantial shares of the growing inequities for every group studied –blacks, whites, men and women.

Moreover, the other so-called deaths of despair – suicide and alcoholic liver disease— explained little to none of growing inequity for any group, raising serious questions about whether it is right to classify opioid deaths as “deaths of despair” rather than focus on their increasing availability, over-prescription, and the explosion of more lethal forms such as black tar heroin and fentanyl on the illegal market.

MedicalResearch.com: What should readers take away from your report?

Response: As we tackle the opioid epidemic, we should not lose sight of the widening educational mortality gap attributed to CVD, cancers, and other internal causes. Our findings suggest that the less educated may be dying not only or primarily from hopelessness and maladaptive coping through alcohol or opioid abuse but perhaps from engaging in high-effort coping with adversity, reflecting the hopeful belief that their economic uncertainty can be overcome with effort and tenacity.

In our unequal economy working class Americans who persist face chronic stressors as they work tenaciously to support their families and overcome the obstacles they face. They may hold multiple low-skilled, low wage jobs, with constantly shifting schedules and few benefits; lose sleep juggling childcare and transportation issues; live or work in unhealthy environments, and struggle to meet high rents, evictions, and exorbitant health care costs, all with a weak safety net. 

This chronic and toxic stress can wear out our body systems and physiological resistance, and we can become prone to heart disease, cancers, and even accelerated biological aging of our cells. Perhaps this has contributed to the growing educational inequities in life expectancy. 

MedicalResearch.com: What recommendations do you have for future research as a result of this work? 

Response: Researchers should work to better understand how being among the least educated in America increases your probability of dying from cancers, cardiovascular diseases, and other internal causes relative to the more educated. This may in part be due to medical underservice and unhealthy behaviors, however smoking rates and lack of health insurance have been declining among the less educated during the same time period that mortality gaps have grown, and cancers other than lung have contributed the most to increasing cancer death disparities.

Results underline the speculative nature of attempts to attribute trends in life-expectancy inequity to an epidemic of despair. Better understanding of the lived experience of the least educated Americans and how their everyday experience may expose them to premature death or bar them from reaping the full measure of extended life expectancy now available to more educated Americans is a critical direction for future research. 

MedicalResearch.com: Is there anything else you would like to add?

Response: While we must address the opioid epidemic on its own merits, without greater evidence, we recommend that researchers be cautious in their use of DOD as a shortcut label to lend explanatory credibility to its underlying narrative of hopelessness. The DOD label overlooks black lives and implies that a lack of resilience explains LE inequities among whites even as a growing body of empirical evidence suggests that resilience is characteristic of many socioeconomically disenfranchised U.S. populations and that the process of persistent, high-effort coping itself can have adverse health repercussions. 


Arline T. Geronimus, John Bound, Timothy A. Waidmann, Javier M. Rodriguez, Brenden Timpe. Weathering, Drugs, and Whack-a-Mole: Fundamental and Proximate Causes of Widening Educational Inequity in U.S. Life Expectancy by Sex and Race, 1990–2015. Journal of Health and Social Behavior, 2019; 60 (2): 222 DOI: 1177/0022146519849932 

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Last Updated on June 16, 2019 by Marie Benz MD FAAD