Far too many Americans are dying from preventable causes, and each time we make progress it seems like new problems appear. Take the case of opioid overdoses. As we are beginning to get a handle on misuse of prescription opioids, fentanyl and synthetic opioids have come to the fore. Two decades ago, they were linked to fewer than 1,000 deaths each year. In 2017, fentanyl and synthetic opioids killed more than 28,000 Americans.

The emphasis on opioids is appropriate, but too narrow. The underlying conditions that often lead to drug misuse can also lead to alcohol misuse, loneliness, and despair. Even as America is experiencing surging rates of drug misuse, the nation is also witnessing an unprecedented rate of suicide deaths, which rose 6 percent between 2016 and 2017, and with alarming increases among children and adolescents.

Overall, more than 150,000 Americans — the most ever — died from alcohol and drug-induced fatalities and suicide in 2017. That’s more than twice as many as in 1999, according to a new analysis released on Tuesday by our organizations, Well Being Trust and Trust for America’s Health.

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To truly tackle complex, deeply rooted societal problems like these, we need to transform fragmented and disjointed community systems. Deaths from substance misuse and suicide are symptoms of broader problems. If we treat only the symptoms, more and more people will be at risk and die needlessly.

To address the underlying causes, we need a comprehensive approach that includes increasing funding and support for programs that reduce risk factors for despair and promote resilience in children, families, and communities. Exposure to trauma and adverse life experiences at young ages increases the potential for substance misuse and suicide. Programs that reduce community violence; address poverty and discrimination; create safe, supportive schools and quality learning experiences; and promote access to secure housing and employment opportunities can decrease adverse experiences and build resilience.

For example, the Nurse-Family Partnership works with young, low-income women who are pregnant for the first time. A public health nurse meets with the mother from pregnancy until the child turns 2, establishing a trusted relationship with both. The home visits connect first-time mothers with the care and support they need to ensure a healthy pregnancy and birth. The model has been shown to have dramatic benefits to society. For instance, when Medicaid pays for Nurse-Family Partnership services, the federal government gets a 54 percent return on its investment.

Along that line, the nation should expand substance misuse prevention and mental health programs in schools by increasing the number of schools that get training for, can screen for, and can respond to childhood trauma. Schools should also be supported in scaling up evidence-based life- and coping-skills programs like the Good Behavior Game, and increasing the availability of culturally appropriate mental health and other services.

Schools should also work with other community agencies to assist the families of the children who have experienced trauma. Successful school substance misuse prevention programs return $3.80 to $34 for every $1 invested; social-emotional learning programs provide an $11 for $1 return; and school violence prevention programs (including suicide) have a $15 to $81 return.

The nation will see results only if it addresses the need for a multigenerational response that includes substance use disorder treatment for parents and additional support for all caregivers while also expanding resources for the foster care system.

Model programs have been effective in helping mothers achieve sobriety, reducing state custody placement of children by half and producing a strong return on investment. Sobriety Treatment and Recovery Teams (START), for example, is a Kentucky-based program for families with parental substance use disorders and issues of child abuse and/or neglect. It helps parents achieve sobriety and, when possible, keeps children safely with their parents. Mothers who participated in START achieved sobriety at nearly twice the rate of those not in the program and children in START families were half as likely to be placed in state custody. For every dollar spent on START, Kentucky avoided spending $2.22 on foster care.

Policymakers should create, and clinicians should support, policies that limit access to the lethal means of suicide by promoting safe storage of medications and firearms — completed suicides with a firearm have increased 22 percent over the last decade. The Counseling on Access to Lethal Means model has improved medication and firearm storage behavior through parental counseling. One Colorado study, focusing on parental counseling for suicidal youth in the emergency department, found 100 percent of firearms locked up at follow-up.

These more upstream approaches should be seen as essential elements of a comprehensive approach that includes the more downstream availability of treatment. While the continuum of services is essential for all populations, we must place focused attention on access to programs for communities and population groups at the highest risk for substance misuse and suicide.

Every American — from policymakers and public health advocates to parents, caregivers, clinicians, and counselors — should demand that community leaders develop and fund a comprehensive strategy that includes the elements laid out above and so much more.

Continually rising deaths from despair and trauma are unacceptable and, perhaps most importantly, they are preventable. America’s leaders need to direct resources toward comprehensive solutions that truly integrate physical health, mental health, and substance-use disorder services in a way that prioritizes prevention and more adequately addresses community demand.

Let’s not wait for the next crisis, or ride out this one for another decade, to decide that now is the time to invest in prevention.

Benjamin F. Miller is chief policy officer for Well Being Trust, a national foundation advancing the mental, social, and spiritual health of the nation, and founding director of the Eugene S. Farley Jr. Health Policy Center in Aurora, Colo., where he remains a senior adviser. John Auerbach is president and CEO of Trust for America’s Health, a nonprofit, nonpartisan organization dedicated to making disease prevention a national priority.

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  • Deaths of despair and the rise of suicide are all related to outsourcing. One day a person has a job and then two weeks later, someone in India has that job. Yet, the CEO and all vice presidents still make even more money. There are no jobs. The rich get richer and the middle class is dying away. Sheer greed will bring this country to its knees eventually, once no one can afford to buy a house, pay rent, buy a car or even afford groceries without government help.

  • So, Mavis and Jonathan, I wish you were both in front of me at the cafe I’m at now, so we could have a talk. It seems we are much in agreement that naming the symptoms of our problems is not the same as naming the underling causes and planning action to address them. And yes, of course, it’s political.

    The difference between Republicans and Democrats these days seems to to be the difference between the 99% of us getting more crumbs from the Table of Capitalism or fewer crumbs. Everyone who works should get a fair slice of the whole cake, not just fewer crumbs or more crumbs. This country is wealthy and productive enough for everyone to have opportunity and for there still to be very wealthy people. Just not obscenely, foolishly, dangerously wealthy people, like the top three (3) people controlling half the country’s wealth (https://www.scmp.com/news/world/united-states-canada/article/2119052/three-richest-people-us-own-much-wealth-bottom-half). That’s capitalism run amok. There are a few billionaires who speak out on this, like Nick Hanauer (https://www.politico.com/magazine/story/2014/06/the-pitchforks-are-coming-for-us-plutocrats-108014), who know this situation is untenable for the United States. I’m fine personally with capitalism, providing it is wisely and sufficiently regulated, which has not been the case for a few decades.

    Elizabeth Warren, Bernie Sanders and Alexandria Ocasio-Cortez all propose different strategies for undoing the massive, inexorable redistribution of wealth and opportunity that has been flowing upward from poor, working and middle class people to the wealthiest people over the past 30-40 years, notably with George W. Bush’s tax cuts, Trump’s tax cuts, all kinds of loopholes and especially since the “recovery” from the Great Recession. Robert Reich and many others have clearly documented and explained the disparities in wealth and income and the many causes.

    Maybe this is a moment in time that the young – and the old and the in-between – can reclaim a decent and fair standard of living – and hope – for our children and families, our elders, the sick, the poor and all working people. This country can do it if we want to do it. And yes, it’s very political. The class war started a long time, only we didn’t fully see it or were afraid to talk about it. It is patriotic to name it and address it.

    • Thanks Jeff Stone,
      I am trying to remain optimistic about our heroic people like Bernie, Warren, and AOC. They are under attack constantly by mass media. Jut like in healthcare, our politics is contant Gas Lighting and misinformation.

      The Class War has been ongoing for a long time, and the resluts have been nearly genocidal. Many of my friends and acqaintances are caring for their adult children and grandchildren. Their adult children are incapable of taking care of their children, or have died. There are others who are caregivers for brain damaged children, the results of overdosese. Some are also caregiving their husbands who are older veterans with serious health problems like cancer.
      They just found out that one community here, with a high rate of overdoses, suicides, and poverty had Nitrates in their water. The state was supposed to be monitoring that. Around here any factual information gets burried if it might make the realtors uncomfortable. A homeless veteran died in front of the Starbucks, and no one cared.
      They are in denial around here about the Epidemic of Despair, they created a counter narrative of “prosperity” and only incrementally raised the minimum wage.

  • This sounds nice, but it does not go far enough. This is the kind of Gas Ligthing that got us all here. These incremental and short term interventions just don’t add up. They just make it sound like someone is dealign with this issue. They have a very narrow view fo the facts. They believe they can create resliliance, without looking at how resillance is developed.
    What we are dealing with is the Despair associated with years of Neo Liberal Ideology. We have a traumatized population with no hope of a future. Every asset in our society has been monetized, and destroyed. Nearly 50 percent of americans, don’t have 400 dollars in their accounts to deal with an emergency. Waht we have is a breakdown of societal norms, and a misinformaion campaign telling us that it is not happening.
    People should have been concerned when it effected children, yet this kind of half measure is being trumpeted as if is is meanignfull. These public health people are still so out of touch, it is escrucaiting. Children in many communities are dying,and no longer have any expectaion of growong up, or a future. Articles like this perpetuate the lies and denial over this Epidemic of Despair.

  • This is an important piece, and the recommendations are sound, but I have a concern about the focus.

    The authors’ write:

    “To address the underlying causes, we need a comprehensive approach that includes increasing funding and support for programs that reduce risk factors for despair and promote resilience in children, families, and communities. Exposure to trauma and adverse life experiences at young ages increases the potential for substance misuse and suicide. Programs that reduce community violence; address poverty and discrimination; create sTo address the underlying causes, we need a comprehensive approach that includes increasing funding and support for programs that reduce risk factors for despair and promote resilience in children, families, and communities. Exposure to trauma and adverse life experiences at young ages increases the potential for substance misuse and suicide. Programs that reduce community violence; address poverty and discrimination; create safe, supportive schools and quality learning experiences; and promote access to secure housing and employment opportunities can decrease adverse experiences and build resilience.; and promote access to secure housing and employment opportunities can decrease adverse experiences and build resilience.”

    This seems to me to be the key point. But what I would argue are the most significant elements here — those elements that really addressing the social determinants of health that result in deaths of despair — get lost almost completely in the rest of the paper. There are no details about what it would mean to address poverty and discrimination (and I would argue that leaving inequality off the list seems profoundly misguided), and the material on schools below isn’t about creating “safe, supportive schools and quality learning experiences,” but rather about getting schools more involved in helping children deal with trauma etc. (which is important, but not the same thing at all).

    Or again, surely promoting “access to secure housing and employment opportunities” is critical to addressing the so-called diseases of despair, but after that single mention, this gets lost in a slew of specific policy recommendations that don’t in fact address these underlying causes.

    It might be that we can’t (won’t), as a society, in fact address the underlying causes of the diseases of despair, because we are unwilling to seriously confront our out of control economic inequality and the attendant systematic stripping away of meaningful opportunities for satisfying work for much of our population. But if that is so, I think that needs to be said clearly, rather than hiding the key recommendations in a paragraph that is then all-but forgotten in the rest of the paper.

    • My reaction was the same as yours, Jonathan Kaplan. Addressing poverty and disparities in housing, education and employment are gigantic challenges that would require a gigantic re-allocation of resources, which this wealthy country could afford, and political heavy-lifting. Inevitably it boils down to political choices favoring the well-being of the many over the few and whether we will have the courage to organize and push for them. BTW, I am not talking about tearing down capitalism. The United States can have very wealthy people as well as “truly tackle complex, deeply rooted societal problems.”

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