A presentation delivered by Eric Schneider, MD on November 13, 2018 to the National Association of Medicaid Directors. ‘Deaths of Despair’ (suicide, alcohol, and drug overdose) are up in every state. Why do they matter, and what might guide state responses?

1. Deaths of Despair:
A Clarion Call for State Action
Eric C. Schneider, MD, MSc, FACP
November 13, 2018
National Association of Medicaid Directors

2. 2
•Why do “deaths of despair”
matter?
•What is driving the
mortality trends?
•What might guide state
responses?
Measuring State Health System
Performance to Inform Improvement

3. 3
Premature death rates from treatable
medical conditions rose unexpectedly
Deaths per 100,000 population
State rates
U.S. average
Note: Y-axis starts at 50 deaths per 100,000. Dashed line represents the expected premature death rate if the historical trend from 2004-05 to 2012-13 had continued
in 2014-15. Premature deaths reported here do not include deaths from suicide, alcohol, or drug use; see appendix for complete list of health care amenable deaths.
Data: 2004–2015 National Vital Statistics System (NVSS) Mortality All-County Micro Data Files.
Source: D.C. Radley, D. McCarthy, and S.L. Hayes, 2018 Scorecard on State Health System
Performance, The Commonwealth Fund, May 2018.

4. 4
Data: 2015 National Vital Statistics System (NVSS), via CDC WONDER (despair); National
Center for Health Statistics. Health, United States, 2016: With Chartbook on Long-term
Trends in Health (other causes). Hyattsville, MD. 2017
Deaths of despair the only leading
cause of death trending upward
Deaths per 100,000
0
50
100
150
200
Heart
Disease
Cancer Deaths
of
Despair
Lung
Disease
(COPD)
Stroke Diabetes Pneumonia
& Flu
2005 2015

5. 5
• Suicide
- Self-inflicted injuries
• Alcohol
- Liver disease
- Accidental poisoning by and exposure to alcohol
• Drugs
- Opioids, sedatives, hypnotics, antianxiety drugs
- Adverse effects of prescription drugs & medication errors (very
few)
Deaths of Despair Defined
Data: 2005 & 2016 National Vital Statistics System (NVSS), via CDC WONDER
Source: Case A, Deaton A. Rising morbidity and mortality in midlife among white non-
Hispanic Americans in the 21st century. Proceedings of the National Academy of
Sciences. 2015 Dec 8;112(49):15078-83.

6. 6
Data: 2005 & 2016 National Vital Statistics System (NVSS), via CDC WONDER
Source: D.C. Radley, D. McCarthy, and S.L. Hayes, 2018 Scorecard on State Health
System Performance, The Commonwealth Fund, May 2018.
Deaths of despair up in all states
28.5 – 29.9 (1 state)
30.0 – 39.9 (13 states)
40.0 – 49.9 (18 states)
50.0 – 83.1 (18 states + D.C.)
Deaths per 1000,000
16.4 – 29.9 (26 states + D.C.)
30.0 – 39.9 (20 states)
40.0 – 49.9 (4 states)
50.0 or higher (0 states)
Deaths per 100,000
2005 2016
W.V.
83.1

7. 7
Data: 2005–2016 National Vital Statistics System (NVSS), via CDC WONDER
Source: D.C. Radley, D. McCarthy, and S.L. Hayes, 2018 Scorecard on State Health
System Performance, The Commonwealth Fund, May 2018.
Deaths of despair rising in some
states much faster than in others
Deaths per 100,000
State rates
U.S. average
West Virginia

8. 8
9.1
11.5
10.9
13.5
8.6
18.3
28.6
43.2
0
5
10
15
20
25
30
35
40
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Age-adjustedU.S.deathrateper100,000
people
Data: 2005–2016 National Vital Statistics System (NVSS), via CDC WONDER
Source: S.L. Hayes, D.C. Radley, and D. McCarthy, "States of Despair: A Closer Look at
Rising State Death Rates from Drugs, Alcohol, and Suicide," To the Point (blog),
Commonwealth Fund, Aug. 9, 2018.
Deaths from Drug Overdose Double: Now
Leading Contributor to Deaths of Despair
Deaths of Despair
(combined rate from all
three causes)
Suicide
Alcohol
Drugs
51%
113%
24%
26%
Cumulative increase
2005 – 2016

9. 9
22
4
8
11
29
5 10
13
33
10 10
13
83
50
14
19
0
10
20
30
40
50
60
70
80
Note: Lowest- and highest-rate states for Deaths of Despair composite in 2016 selected.
Data: 2005–2016 National Vital Statistics System (NVSS), via CDC WONDER
Source: S.L. Hayes, D.C. Radley, and D. McCarthy, "States of Despair: A Closer Look at Rising
State Death Rates from Drugs, Alcohol, and Suicide," To the Point (blog), Commonwealth Fund,
Aug. 9, 2018.
Lowest- and Highest-Rate States
Experienced Different Rates of Change
Nebraska West
Virginia
Nebraska West
Virginia
Deaths of Despair
(combined rate from
all three causes)
Drug Overdose
Deaths
Alcohol Deaths Suicide
2005
2016
Deaths per 1000,000
Nebraska West
Virginia
Nebraska West
Virginia

10. 10
Overdose Deaths Involving Opioids, by
Type of Opioid, United States, 2000-2016
Source: CDC/NCHS, National Vital Statistics System, Mortality, CDC
WONDER, Atlanta, GA: US Department of Health and Human Services,
CDC; 2015. www.wonder.cdc.gov. Obtained from:
https://www.senpf.org/opioid-crisis.html

11. 11
• Vulnerability Multipliers
• Over-prescribing
• Illicit suppliers
• Criminal justice response
• Limited employment
opportunities
• Limited education and
training
• Delivery system
weaknesses
• Success Factors
• Leadership commitment
• Formalize multi-agency working
groups
• Engage all front-line stakeholders
• Monitor progress via responsible,
timely data sharing
Multi-factor Epidemic:
Multi-pronged State Actions

12. 12
• Reduce Opioid Supply
- Guidelines and limits on opioid prescription
- Monitor unnecessary opioid prescribing
• Expand Treatment
- Expand medication-assisted treatment (buprenorphine)
- Increase access to opioid antagonists (naloxone)
- Monitor access to treatment
• Prevent Addiction
- Primary care integrating medical, behavioral, and addiction
services
- Accessible mental health care services
Areas of Focus for Medicaid

13. 13
Medication-Assisted Treatment
(Buprenorphine) Can Make a Difference
Source: Buprenorphine Use: The International Experience
Clin Infect Dis. 2006;43(Supplement_4):S197-S215. doi:10.1086/508184
Clin Infect Dis | © 2006 by the Infectious Diseases Society of America

14. 14
States using emergency opioid grant
funding in different ways
Source: “AP analysis: ‘Obamacare’ shapes opioid grant spending.” AP,
October 22, 2018,
https://www.apnews.com/8866670406e84ac38dbbbd80a3426f5e

15. 15
• ‘Deaths of Despair’ (suicide, alcohol, and drug overdose)
are up in every state. Opioids the largest contributor to
increasing mortality
• Medicaid can play a key role in controlling prescribed
opioid supply, expanding medication-assisted addiction
treatment, strengthening primary care and behavioral
health integration, and monitoring efforts
• No magic bullet: take advantage of state actions to
learn about solutions that can be effective
Summary & Implications