Trends in Mortality From Drug Poisonings, Suicide, and Alcohol-Induced Deaths in the United States From 2000 to 2017
Research article
Abstract
Importance
Life expectancy has decreased in the U.S., driven largely by increases in drug poisoning, suicide, and alcohol-induced deaths. Assessing whether patterns of these causes differ is required to inform public health interventions.
Objective
To compare patterns and trends in drug poisoning, suicide, and alcohol-induced death rates by geography and demographic characteristics.
Design, Setting, and Participants
This serial cross-sectional study used national vital statistics data from the entire U.S. population from January 1, 2000, to December 31, 2017, among U.S. residents aged 20 to 64 years. Data were analyzed from January through August 2019.
Exposures
Age, sex, race/ethnicity, county-level percentage of unemployment, rurality, and geography.
Main Outcomes and Measures
Deaths were categorized as due to drug poisoning, suicide, or alcohol-induced causes based on underlying cause of death.
Age-standardized incidence rates and annual percentage changes (APCs) in rates were estimated.
Clusters of high-rate counties were identified with hot spot analysis. Excess deaths during 2001 to 2017 were estimated for each cause as the difference between the number of deaths observed and expected if rates had remained stable starting in 2000.
Results
During 2000 to 2017, 1 ,446, 177 drug poisoning, suicide, and alcohol-induced premature deaths occurred in the U.S., including 563,765 drug poisoning deaths, 517,679 suicides, and 364, 733 alcohol-induced deaths*, totaling 451,596 more deaths than expected based on 2000 rates.
High drug poisoning death rates were clustered in the Northeast through Appalachia, yet rates of suicide and alcohol-induced deaths* were highest in the West.
Only suicide death rates were highest in rural areas.
Drug poisoning death rates were highest among people aged 35 to 49 years, whereas suicide and alcohol-induced death rates peaked among people aged 50 to 64 years.
Increases occurred over time across racial/ethnic groups, although trajectories and inflection years varied.
Drug poisoning and alcohol-induced death* rates have accelerated recently, while increases in suicide death rates have largely increased at a constant trajectory.
Conclusions and Relevance
This cross-sectional study found that demographic characteristics and geographic patterns varied by cause of death, suggesting that increasing death rates from these causes were not concentrated in one group or region. Specialized interventions tailored for the underlying drivers of each cause of death are urgently needed.
*Alcohol-induced deaths only include those deaths that are most clearly associated with alcohol use and do not consider other causes of death (eg, certain cancers, motor vehicle crashes) for which alcohol is a strong contributor, thus underestimating the true mortality burden due to alcohol.
Key Points
Question
What are the patterns and trends in U.S. drug poisoning, suicide, and alcohol-induced premature death rates by geography and demographic characteristics?
Findings
In this serial cross-sectional study using U.S. mortality data from 2000 to 2017, including 1,446,177 drug poisoning, suicide, and alcohol-induced premature deaths, high drug poisoning death rates were clustered in the Northeast through Appalachia but high rates for suicide and alcohol-induced deaths were largely in the West. Death rates varied across these three causes by demographic characteristics, county-level characteristics, and over time.
Accelerating alcohol deaths
- Alcohol-induced deaths increased 1.4-fold during 1999 to 2017.
- Alcohol-induced death rates started increasing during 2005 to 2012 and accelerated to 4.1% per year during 2012 to 2017.
- These increases indicate an additional 47,978 alcohol-induced deaths, during 2001 to 2017 more than what would have occurred if the death rates in 2000 had persisted.
- Alcohol-induced death rates began increasing in 2005 among men and in 2000 among women and accelerated in more recent years
Alcohol deaths increase with age
- Alcohol-induced death rates increased with age.
- Alcohol-induced death rates among individuals aged 50 to 64 years were on par with drug poisoning death rates among those aged 35 to 49 years.
Alcohol death rates and ethnic groups
- Alcohol-induced death rates were higher among American Indian and Alaska Native individuals than White individuals and Latino individuals, the two groups with the next highest rates.
- While alcohol-induced death rates significantly increased across 2000 to 2017 among White, Asian, and American Indian and Alaska Native, significant increases were only observed during 2012 to 2017 among Black individuals and Latino individuals.
Alcohol deaths and socio-economic status
- Alcohol-induced death rates were highest in counties in the highest quintile of unemployment and lowest in the lowest quintile.
Alcohol death rates and geographic location
- Alcohol-induced deaths were highest in the smallest metropolitan and largest urban counties.
- The significant hot spots in suicide and alcohol-induced death rates were largely confined to the western half of the U.S., with hot spots for both causes of death from Montana and North Dakota to New Mexico and Arizona.
- Hot spots for of all three causes were present in New Mexico and Colorado.
- Alcohol-induced death rates increased significantly during 2000 to 2017 in nearly every state and Washington, D.C.
Meaning
To target interventions to high-risk groups, whether economically, clinically, or public health-focused, it is critical to understand if the highest rates and greatest increases over time in drug poisoning, suicide, and alcohol-induced death rates have occurred in the same demographic groups and geographic areas.
This cross-sectional study found that demographic and geographic patterns varied by cause of death, suggesting that these causes of death were not concentrated in one group or region and tailored interventions to each cause are urgently needed.
Increases in alcohol-induced death rates began more recently (in 2005) than drug poisoning, and accelerated during 2012 to 2017. Rates of alcohol-induced deaths were highest during 2013 to 2017 among individuals aged 50 to 64 years but increased most rapidly among individuals aged 20 to 34 years and are exceedingly high among American Indian and Alaska Native individuals.
Increasing alcohol-induced death rates are consistent with the increasing prevalence of alcohol use, high-risk alcohol consumption, and alcohol-use disorders. As most alcohol-induced deaths were coded as alcoholic liver disease or other conditions driven by chronic alcohol use and progressive liver damage, it is likely that the more recent trends in death rates reflect a mixture of short- and long-term effects of heavy alcohol consumption.
Reasons for accelerating alcohol death rates
It has been proposed that worsening opportunities in the labor market among White individuals, particularly those with no more than a high school education, have contributed to increasing death rates from drug poisoning, suicide, and alcohol during middle age.
However, other factors likely also contribute.
Increasing drug poisoning, suicide, and alcohol-induced death rates in the U.S. are not limited to White individuals; furthermore, demographic and geographic patterns of these three causes of death differ substantially, indicating a more nuanced and complex picture.
The study’s findings indicate that these three causes of death merit individual consideration, and their underlying causes and optimal prevention strategies may differ in nature, intensity, and duration across populations and contexts.
Many deaths due to drug poisoning, suicide, and alcohol-induced causes may be broadly associated with underlying feelings of despair, whether driven by lack of economic opportunity or other factors. However, each cause of death also reflects access to drugs, alcohol, firearms, and other means of suicide.
Although some policies aimed at prevention can be applied universally, population- and epidemic-specific targeted interventions are likely also needed. In addition, the US Preventive Services Task Force recommends that primary care clinicians screen adults for alcohol use disorder and provide behavioral counseling interventions to those who engage in heavy alcohol use.