Deaths from Despair: Part 1A

Predicting the future outcomes using data from the past has its limits. If the future is "written in stone," then the stones are rarely if ever available when one is doing prognostication. This is especially true when one is attempting to prognosticate what humans will do in the future. 

Scientists creating models of climate change have it somewhat "easier" than psychologist and sociologist when it comes to creating more accurate predictive models. Their models are based on more knowable things such as physics and chemistry. And even they have gotten things wrong although over the decades their models have become much more precise as more data has been collected enabling them to adjust their models and also adding more variables to their models. Finally, the addition of greater and greater super computing power hasn't hurt either. There are times that I envy them. But then I take a look at what they're predicting, knowing that their predictions are firmly based, and my blood runs cold. I haven't yet broken into a cold sweat, but I've come close. These models are flashing red warning signals. 

And here's something more to consider, one area where these models have not quite been matching up with the actual data is in the timing of events. It appears that the predicted changes are coming at a much faster rate than originally predicted. This seems even to be the case with the more recent models.

But I digress ... 

Allow me to get the points I wanted to share. 

A Clarification

I wrote what I did above in order to point out an apparent discrepancy between the drug overdose deaths model and the deaths from despair in their predictions for the crude rates and number of deaths from 2017 to 2025. As it turns out the prediction crude rate and number of deaths from drug overdoses are larger in 2025 than the deaths from despair. 

Predicted Deaths from Drug Overdoses

Predicted Deaths from Despair

What is clear is the drug overdoses has comprised the major portion of deaths from despair. Nevertheless, why does the model for drug overdoses predict a higher number of deaths than the model for deaths of despair.

The problem falls largely with trying to fit a model to the existing data that best explains and enables one to predict the future. Clearly the best model for the drug overdose deaths was the fourth order model that showed greater acceleration than the third order model for the deaths from despair. Deaths from despair include two components suicides and alcohol related deaths that have not been increasing at the rate of drug overdose deaths. Thus when it comes to the actual data, deaths from despair is shifted upwards overall from 1999 to 2017 as you can see, but not accelerating as quickly as drug overdose deaths. Thus the seeming impossibility between the predictions for drug overdoses greater than deaths from despair for 2018 to 2025.

Nevertheless, what is more important is the clarity of the message that both curves are accelerating, meaning that the rate of change is expected to increase year to year. And the rate of change of the curves does not bode well for the future. The hope is that the 1) the rate of change will stop increasing and 2) that soon an inflection point will occur and the curves will begin to point downward. These curves provide a warning namely that based on current data predicting that the future doesn't look promising. I believe that is the major takeaway. Let's hope that these predictions are wrong.

As a side note, I wish the predictions regarding climate change are wrong ... but they're not. And we need to do something about it. But I digress ...

Deaths from Despair Part 1

I became interested in deaths from despair as a result of two articles published in the New York Times in 2018 of summaries of the research from Case and Deaton on the raising rate of deaths from despair particularly among US Whites. Here are links to those articles:

• https://www.nytimes.com/2015/11/03/insider/more-white-men-die-from-suicide-and-substance-abuse-why.html?searchResultPosition=2
• https://www.nytimes.com/2015/11/03/health/death-rates-rising-for-middle-aged-white-americans-study-finds.html?searchResultPosition=3

My interest has been rekindled largely by the recent reports that US life expectancy had dropped over a three year period. Here's a link to one of those articles from the Washington Post: https://www.washingtonpost.com/health/theres-something-terribly-wrong-americans-are-dying-young-at-alarming-rates/2019/11/25/d88b28ec-0d6a-11ea-8397-a955cd542d00_story.html

I've already analyzed data obtained from CDC's Wonder (https://wonder.cdc.gov) database on suicides and drug overdose deaths. I've discussed them in this blog. In addition, I've collected from Wonder on alcohol-related deaths. Combined, these three categories have been defined as deaths resulting from despair as defined by Case and Deaton of Princeton University (Mortality and Morbidity in the 21st Century, 2017) and by a follow-up study to Case and Deaton's research by the Senate Joint Economic Committee (Long-Term Trends in Deaths of Despair). The Senate Report defined alcohol related deaths somewhat differently than Case and Deaton, nevertheless, the numbers from both studies tell the same story. 

A Series on Deaths from Despair

I've decided to do a series of articles focusing on different aspects of Deaths from Despair. All indications are that the US is in trouble and deaths from despair provide strong indications of the level of that trouble. 

My interest in this area has additionally been motivated by my curiosity of those who follow and revere Donald Trump. It seems that so many of them see Trump as a kind of savior, someone who will magically lift them out of their perils. What I have also found in my analysis of suicides and drug overdose deaths, that those people who seem to cling most strongly to Trump are the ones most likely to die an untimely death by suicide or a drug overdose. The sad part is that these people are clearly in need, clearly hurting but as anyone who has been paying attention: Trump like all con-men will promise them anything and everything, but takes everything he can for himself, his family members and his cronies. Yet Trump's followers continue to revere him, remain enthralled and part of his cult of personality in spite of the fact that Trump has given them nothing but his vitriol to cling to. 

(As a side note, my late cousin was the leader of a cult, the Living Word Fellowship, so I have some understanding how cult leaders operate: how they gather and hold on to their membership while finding every way possible to exploit them. I have been completely amazed that so many of these abused people have continued to remain in the cult. Even the so many of the ones who have left continue to focus much of their energy and attention on the cult and the cult leaders. Somehow the cult fulfills a need or needs in its followers that locks them in. 

Since I'm related to the cult leader, I understand the viewpoint of the leader of the cult. I don't have a clear understanding of those who comprise the membership, but I have seen, heard and read snippets from followers and former followers. I don't like what I've learned. These are people who have been exploited and brutalized, yet they come back from more. I don't believe I'll ever understand them.)

In this article, I'll focus on one or two areas related to deaths from despair. Later articles on this topic will focus on one or two areas of interest with deep dives into the data and what current data can project for the future.

Overview: Deaths from Despair 1999 to 2017 

The figure below shows the number of deaths from despair (combined: suicides, drug overdoses and alcohol related) from 1999 to 2017 obtained from Wonder. 

The best fit trend line can be found in upper left of the chart. Note that this is a 3rd order increasing curve. This is the equation used to predict future outcomes.

As mentioned in an earlier article, CDC announced that drug overdose deaths for 2018 dropped from 2017. However, 2018 data has not been loaded on to Wonder. As I have noted in an earlier article, the number of deaths can change from the announcement to their inclusion into Wonder. For now, I'll use only that data currently available in Wonder. When the numbers from 2018 have been included into Wonder, I'll include that data and make any necessary revisions to my analysis.

One of the things I noted in both studies, is that both studies use normalized data such as crude rates (number per 100,000 population) and percentages. And this makes complete sense when you're comparing one year to the next and in studies such as these. However, when you look at the raw numbers of deaths from despair, the scale of the problem (or problems) we're confronting hits home as shown in the figure below. 

From 1999 to 2017 the number of deaths has risen from nearly 68,000 to nearly 157,000 people living in the US. And over the last 10 year, the number of deaths from despair totals over 1.2 million people. The US crossed into over 100,000 deaths from despair per year in 2009. The world was in the middle of the financial crisis in 2009 and the economy was in downward spiral. An high number of deaths from despair would not be unexpected, but one would hope that as the economy got better, the number of deaths from despair would start to drop. Instead they continued to rise and at an accelerating rate due largely to the opioid addiction crisis in which the US has found itself locked in battle. However, having said this, suicides and alcohol related deaths have also continued to rise, although at a lower rate of increase than drug overdose deaths. (Interestingly enough, drug overdoses as the manner of death in suicides has decreased over the last several years while death by firearm and suffocation/strangulation have continued to increase.)

Projections to 2025

The figure below shows a projects a continuing increase in the crude rate of deaths from despair to 2025. 

The projection of the number of deaths to 2025 puts the problem in clear and stark terms as shown in the figure below.

One can only hope that somehow the staggering rate of increase will be at least slowed, if not stopped. The death rate and numbers for 2017 are unacceptable and suggest that the US has a serious social problem in its midst that needs to be addressed. But a country the size of the US with over 300,000 deaths from despair in a single year with 2.2 million deaths in the last 10 years could only be described as catastrophic. 

Drug Deaths 2018, Early Data from the CDC

Within hours of posting my previous article regarding projected deaths for drug overdoses, the CDC reported their early data on drug deaths for 2018. [I don't consider the CDC data to be finalized until it has been added to the Wonder Database (CDC Wonder Database).] Nevertheless, according to the CDC, there was drop in the number of drug related deaths from 2017 to 2018. And as an added bonus, there was a slight rise in US life expectancy. 

Here's one of the better articles I came across that explains the CDC data is from Vox: https://www.vox.com/policy-and-politics/2020/1/30/21111887/opioid-epidemic-drug-overdose-death-2018

The article reported that the crude rate (number of deaths per 100,000) had decreased to 20.7 in 2018 from 21.7 in 2017. I reviewed all my past data analysis and predictions to see how this new data lined up with of my predictions. Here's what I found:

1. My best fit model that used data from 1999 to 2016 predicted that the crude rate for 2017 and 2018 would be 18.4 and 19.0 respectively. These predictions are strikingly lower than the actual data. And I should mention that this model is a second order, curvilinear, accelerating rate model.
2. My best fit worst case scenario model that used data from 2008 to 2016 predicted 20.1 for 2017 and 23.4 for 2018. Slightly low for 2017 but noticeably high for 2018. Again, this is a second order, curvilinear, accelerating rate model. The rate of acceleration is greater than the model above.
3. My best fit model using the most recent CDC Wonder data from 1999 to 2017 suggested that the crude rate for 2018 would be 27.5. This is a much faster accelerating 4th order model.

Analysis

The apparent primary cause for the striking rise in the death rate for 2017 was due to the increasing availability and use of illegal fentanyl. If the US is going be able to stem the tide of this epidemic, efforts are going to need to be made to reduce the many deaths from fentanyl and its chemical cousins. Is that happening? Consider the follow chart from the Vox article. 

Some of the decrease in drug death rates are likely due to the increased availability of the opioid overdose antidote, naloxone. There's a noticeable down-tick in the death rates across all drug categories suggesting a common factor of influence crossing all categories. However, although all other curves show a downturn in the death rate, deaths due to synthetic opioids (most notably fentanyl) continues to rise although at a lower rate.

So, are we seeing the light at the end of the tunnel of the opioid epidemic? Or is this just the light of a train coming the other direction? The cause for appears to be the reduction in deaths from heroin and natural and semisynthetic opioids. However, the rate of death from synthetic opioids continues to climb and this is the predominant cause of death from drug overdoses. Thus it's clear, this is not anywhere near to being under control.

I'll conclude by quoting from the Vox article that suggests that the underlying causes of the epidemic as well as the supply of drugs remain and remain unaddressed:

... the country still seems to struggle with underlying conditions that experts say are fueling “deaths of despair.” That’s not just drug overdoses but also suicides, which increased in 2018, and alcohol-related deaths, which have doubled in the past two decades. ...

“If all of these social factors were there, and we didn’t have the supply of drugs, of course people would not be dying of overdoses,” Nora Volkow, director of the National Institute on Drug Abuse, previously told me. “But it is the confluence of the widespread markets of drugs — that are very accessible and very potent — and the social-cultural factors that are making people despair and seek out these drugs as a way of escaping.”

All of that leaves America vulnerable to increases in drug addiction cases and overdose deaths, even as it sees some gains due to drops in opioid prescriptions and related deaths.

Update: Public Health Alert: Centers for Disease Control: 2017 and Projections to 2025

I've published two articles in this blog related to drug related deaths. Since then, I've gone back to CDC's Wonder Database (https://wonder.cdc.gov) in order to use their most recent data to rework my models and predictions. What I found shocked me. As you will see below, the number of death reported by the New York Times in the linked article was not 72,300 as reported. It was 73,990 in 2017. The number that the Times reported was well beyond the number that I had predicted in my worst case scenario for 2017 of 69,000 drug related deaths. The updated year 2017 number I extracted from Wonder showed that my worst case number of drug related deaths for 2017 was low by an additional 1700 deaths for a total prediction error of: low by 3,990 deaths. 

Putting my error in perspective: approximately 2240 died in the Pearl Harbor attack; in the 9/11 attacks, 2, 977 people died; from 774 SARS around 2004 and that was a world-wide health crisis; I could go on. This cannot be considered anything other than a catastrophic crisis. 

Going Back to the Source

I decided to go back to the Wonder database and reexamine the drug death data.  This time I included the actual data from 2017 to see how the new data would effect my original predictions.

I queried Wonder for all the drug-related deaths from 1999 to 2017. To understand trends, the best measure is the "crude rate." Crude rate is the number of deaths per 100,000 population. It's similar to a percentage of the population, but instead of 100 being the denominator, it's 100,000.

The results are shown below.

1999 to 2017 Drug Related Deaths (CDC Wonder)

I recalculated my trend line and found that a 4th order equation provided by far the best fit for the data. In fact this trend line appears to provide a nearly perfect description of the data. My original  trend lines (including my worst case trend line) were second order equations. The worst case trend line was based on the data from 2008 to 2016. On the other hand new equation was based on all the available data. The last two years have shown a substantial uptick in the crude rate. 

The actual number of drug related deaths for 1999 to 2017 is shown below. The chart lists the actual number of deaths for each year.

1999 to 2017 Drug Related Deaths (CDC Wonder)

Based on this data we can clear see the effects of the widespread availability and use of fentanyl. 

Projecting Into the Future

Based on the new data and the recalculated trend line, what are the predictions for the crude rate and the number of drug related deaths from 2017 to 2025. 

Using the new equation, I projected might be expected for the future. That is shown in the two charts below.

Projected Crude and Number of Drug Related Deaths to 2025

I want to make clear that these are my projections, not the CDC or another organization. I also want to mention is that the last time I made future projections for drug related deaths, that even my worst case projections were substantially lower than what the actual data would show. So as bad as these numbers are, I consider them not out of the realm of possibility. Nevertheless, based on the equation the actual crude rate data, drug related deaths last year (2019) were over 100,000. And the number of drug related deaths could reach over 400,000 by 2025. That is a staggeringly high number and would make the opioid crisis the origination point for the worst epidemic in US history. With numbers like these US life expectancy will continue to trend downward at an accelerating rate. 

My sense is that the drug related death rate will at some point level out or stop growing at this extremely high rate. However, as of this point, based on the data so far, these are the projections. It will take a couple of years, but I would be interested in knowing the actual number of drug related deaths that occurred in 2019. If the number is anywhere near 100,000, then it's clear that we are riding on a trend line of massively high numbers of drug related deaths into the future. 

Updated: US life expectancy has not kept pace with that of other wealthy countries and is now decreasing: What appears to be causing this?

Here's the reference to the article I that has prompted my analysis into the data that they have collected and a brief summary of their results:

https://jamanetwork.com/journals/jama/fullarticle/2756187?guestaccesskey=c1202c42-e6b9-4c99-a936-0976a270551f&utm_source=for_the_media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=112619

Here's a summary of their conclusions: 

US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.

Life expectancy data for 1959-2016 and cause-specific mortality rates for 1999-2017 were obtained from the US Mortality Database and CDC WONDER.

__________
In my previous two articles that reference this study, I examined data from other countries and in my most recent article, I examined US mortality rates in comparison to US peer countries. If you read that article you'll know that my findings showed that the US is at the bottom of the group. The US life expectancy is even lower than for Puerto Rico. 

The JAMA article referenced above examined US mortality data only, but performed a careful analysis to examine why people died. I think that we can agree that US life expectancy in comparison to other peer countries is lower than it should be. And the fact that it appears to have begun to drop is unacceptable. My question is why? Why is US life expectancy dropping instead of rising? What appears to be the major driver or drivers for this phenomena?

I pulled two figures from the study that appear to show why US life expectancy appears to be dropping over the last three years and why in earlier years the increases in US life expectancy had not kept up with its peer countries. 

Figures 4 and 6 from the JAMA article

Figure 4 clearly shows that the major increasing cause of death in all age categories is drug related -- Drug poisoning. All the other curves remain reasonably flat with one exception, hypertensive diseases for those 55 to 64 years old. One might expect that diabetes would be a contributor given that more and more people in the US are obese, but this is not the case. In each age group, diabetic related deaths are either flat or dropping. (The increase in hypertensive deaths are likely related to the overall increase in obesity.)

Figure 6 breaks down the drug poisoning deaths by Race/Ethnicity from 1999 to 2017. White Americans and American Indians & Alaska Natives show a steady increase in death from a drug overdose. African-American drug overdose deaths appear to have been relatively flat until 2014 when they showed a dramatic and unsettling rise. Both US Hispanics and Asian/Pacific-Islanders show an increase in drug related deaths, but nothing like the others. 

_______

Looks like we have more evidence of the level of significance of the impact of the opioid crisis. 

_______
I've seen references to one of the reasons for the decrease in life expectancy for the from 2015 to 2017 is the increasing rate of suicide. While suicides have been increasing, they've been increasing at a reasonably steady rate from 1999 -- which is the earliest date found from the CDC Wonder database. Suicides have not shown the dramatic and curvilinear rise that drug related deaths have shown. So yes, an increase in suicides is clearly a contributor to the reduction in the US life expectancy, but not a major contributor. 

Quick Follow-up to: US life expectancy has not kept pace with that of other wealthy countries and is now decreasing

I wanted to do a quick update and share a few of my findings on this topic. I compared US life expectancy to our peer countries. These countries or wealthy portions of countries (such as Hong Kong and Macao) in 1960 would have been considered "first world" or "industrialized." 

Comparison list of countries include:

1. Hong Kong SAR, China
2. Japan
3. Macao SAR, China
4. Switzerland
5. Spain
6. Italy
7. Singapore
8. Luxembourg
9. Korea, Rep.
10. Israel
11. France
12. Norway
13. Australia
14. Malta
15. Sweden
16. Canada
17. Iceland
18. Ireland
19. New Zealand
20. Austria
21. Netherlands
22. Belgium
23. Finland
24. Greece
25. United Kingdom
26. Portugal
27. Denmark
28. Germany
29. Puerto Rico
30. United States

I added Puerto Rico and South Korea (Republic of Korea) because Puerto Rico is part of the US but geographically, culturally and linguistically separate as well as significantly poorer and as such provides an interesting comparison. In 1960 South Korea would not have been considered to be a "first world country" but it has grown into one. It's transformation and what that has meant for the citizens of South Korea is interesting as well.

Here's what I found:

1. Since 1983, US life expectancy never again rose above the median. Before 1983, US life expectancy was generally above the median. 
2. In 2012 Puerto Rican life expectancy was higher than the US and has remained higher since.
3. Here's a table of life expectancy for Puerto Rico, US and the median life expectancy for the countries listed above from 2013 to 2017:

                                  

	2013	2014	2015	2016	2017
Puerto Rico	79.03	79.20	79.35	79.49	79.63
United States	78.74	78.84	78.69	78.54	78.54
Group Median	81.75	81.92	81.96	82.24	82.28

Of the listed countries, the US ranks last and has ranked last since 2005. And not only that, US life expectancy has been declining -- at least during the last three years where we have records. I should mention that the country ordering shown above is from highest life expectancy to the lowest based on data collected in 2017.

Finally, if you graph the data, the first 28 countries fall into a fairly cohesive grouping, the Puerto Rico and the US clearly fall outside of that group into a lower grouping since 2011.

From a personal standpoint, the fact that US life expectancy in 2017 is a year lower than Puerto Rico and 3 3/4 year lower than the median is a stunning result. (The highest is over 84 years.)

More to follow on this topic.  

US life expectancy has not kept pace with that of other wealthy countries and is now decreasing

I've analyzed US suicide and drug-related death data. And the results have been striking and concerning. In fact with respect to drug related deaths, I performed a worst case analysis to predict the deaths for 2017. As it turned out, my worst case analysis wasn't nearly bad enough. That was a shocking and saddening realization.

However this is one of the saddest and most concerning studies I have seen regarding indicators regarding life in the US. 

When it comes to life expectancy, the US does better than the world average. But, US life expectancy rate is falling when life expectancy around the world is in virtually every case, increasing. Furthermore, when you look at life expectancy of other countries, the US ranks with Poland and the Czech Republic, not with Japan, Switzerland, the UK, Canada, Spain, Norway, France and others in the EU. Puerto Ricans have a higher life expectancy than those in the US.

Here's the link to the recently published study from the Journal of the American Medical Association (JAMA) that discusses the recent findings.


https://jamanetwork.com/journals/jama/fullarticle/2756187?guestaccesskey=c1202c42-e6b9-4c99-a936-0976a270551f&utm_source=for_the_media&utm_medium=referral&utm_campaign=ftm_links&utm_content=tfl&utm_term=112619

Here's a summary of their conclusions: 

US life expectancy increased for most of the past 60 years, but the rate of increase slowed over time and life expectancy decreased after 2014. A major contributor has been an increase in mortality from specific causes (eg, drug overdoses, suicides, organ system diseases) among young and middle-aged adults of all racial groups, with an onset as early as the 1990s and with the largest relative increases occurring in the Ohio Valley and New England. The implications for public health and the economy are substantial, making it vital to understand the underlying causes.

I wanted to get this out as soon as a saw it. I'll have more to say about this article in a later blog article. I'll add specific comparisons to data from other countries. 

If you're a US health care professional, it's worth your time just to scan the article.