Lifetime risk: a new way to understand deaths from firearms and drug overdoses

Shortly before the coronavirus shuttered schools last spring, I toured a new elementary school in my community in Ohio. But I had a hard time concentrating on the gleaming whiteboards, the new computers, or the cheerfully decorated walls. A new way I had recently devised to put into context deaths from firearms and overdoses kept distracting me.

As I walked through the school, I realized that one child on every floor of the school will likely die from a gunshot and another will die from a drug overdose in the years ahead. If I had been touring a school across the border in West Virginia, one child per classroom will have his or her life ended by an overdose.

The news media and politicians frequently highlight the high toll of deaths from firearms and drug overdoses with annual statistics, like the 40,000 firearm deaths per year, or with death rates, such as 20-plus overdose deaths per year per 100,000 people.

But most people have trouble grasping the real meaning of both the large absolute numbers and the smaller annual rates.

I decided to look at these tragedies in a different way. I used official death certificate data to calculate the chance that an American child will die from a firearm or a drug overdose over the course of a lifetime. Writing in the American Journal of Medicine, I showed that the lifetime risk of dying from firearms is about 1%, meaning that approximately 1 out of every 100 children will die from firearms if current death rates continue. The lifetime risk of dying from a drug overdose is 1.5%, meaning that 1 out of every 70 children will eventually die from overdoses.

These risks vary depending on who you are and where you live. The lifetime risk of firearm death is highest among Black boys: 1 out of every 40 will die from a gunshot. The lifetime risk of overdose death is highest in West Virginia, where 1 out of every 30 children will die from overdoses. It’s worth noting that these are averages, and different individuals may have substantially lower or higher risks. And we can’t ignore that gunshots and overdoses have other outcomes beside death, such as nonfatal injuries, economic costs, and effects on victims’ families and friends.

What can we do to reduce these shocking numbers? Presenting information on lifetime risks is one place to start. It may be a practical way to educate the public and policymakers about the impact of deaths from firearms and overdoses. While absolute numbers of deaths and annual death rates describe mortality over short periods, lifetime risk tells us more about long-term consequences.

Lifetime risk should be included in news stories and government reports and contrasted with lifetime risk of other causes of death and with figures from other countries. For example, the lifetime risk of dying from an overdose is similar to the lifetime risk of dying from colon cancer, the second most deadly cancer among Americans. Firearm deaths per capita in the U.S. are six times more common than in Canada and 50 times more common than in the United Kingdom, two countries that are culturally similar to the United States. Examining changes over time is also enlightening: American drug overdose death rates have more than tripled over the last two decades.

Second, policymakers can deploy a variety of measures to reduce our exposure to, and the consequences of, firearms and potentially lethal drugs. Examples include background checks and waiting periods for gun purchases and improving access to substance use treatment and needle exchange programs.

Third, health providers can advocate for measures likely to reduce deaths. They can ask patients about the presence of firearms in the home, review safe storage practices, and screen for depression. They can also limit or avoid prescribing drugs with overdose potential and carefully monitor patients on such drugs.

It is too soon to know what the impact of Covid-19 will be on deaths from firearms and from drug overdoses. Preliminary estimates suggest that firearm deaths are continuing at high pre-pandemic levels while overdose deaths are increasing.

Lifetime risk calculations assume that future death rates will match current ones. But it does not have to be that way. The big differences in firearm and overdose deaths by race, gender, state, and country, and the sizable changes over time indicate that many deaths from these two sources are not inevitable.

Let’s take sensible steps now to help our children avoid the preventable tragedies of firearm and overdose deaths.

Ashwini Sehgal is a physician at MetroHealth Medical Center and a professor of medicine at Case Western Reserve University, both in Cleveland.