Category Archives: Substance Abuse

Anne Case and Angus Deacon: Deaths of Despair

Dr. Sanjay Gupta for his HBO special and Nicholas Kristof and Cheryl WuDunn for the New York Times, all interviewed Anne Case and her husband Angus Deacon. Both of them are economists from Princeton University but we won’t hold that against them. As she said, “Whites are reporting poorer and poorer health, more and more pain, and more and more social isolation. More depression. Along with this increase in mortality from drugs, alcohol, suicide there is just a lot more morbidity, pain, and social isolation.” Anne Case came up with the expression “deaths of despair” and it has become very popular.

Anne Case and Angus Deaton, conducted an important study of mortality and wrote the book, Mortality and Morbidity in the 21st Century. Dr. Gupta interviewed them for the television show. In that book they described “deaths of despair” as “death by drugs, alcohol and suicide.” According to them, so many people have died from deaths of despair to equal all the people who have died of AIDs since the beginning of the AIDs crisis. Those deaths were enough to cause life expectancy to fall first for whites and then for the entire population. That is a very unusual event.

These people were the children of the people that won the world war and were expected to live glorious lives in the land of the free and the brave. The parents expected their children to do even better than they did. Those expectations were often not met. As Deaton put it, “They were promised the earth but they did not inherit it.” Case said, “in every state but 2, cirrhosis of the liver and alcoholic liver disease went up. And in every state drug poisoning went up. In every state between 1999 and 2015 suicide rates went up for people aged 22 to 64. If you treat people in a really shabby way for long enough bad things happen to them. That happened to African Americans forever and it started to happen to whites with a High School degree or less, starting probably in the mid-seventies. And now bad things are happening to both of those groups.

Dr. Gupta that if we wanted to know the effects of economic decline all we had to do was visit the American Rust Belt.  There they produced more steel than the rest of the world put together. 24 hours a day, 7 days a week smog from those plants went into the atmosphere of American cities.

Swissvale Pennsylvania , according to Eric Horgos, is the valley that is  “the epicenter of the greatest industrial collapse in the entire developed world in the 1980s. 1983 is when economic Armageddon hit them.”

Is it surprising that people who lived a certain way that they liked for 30 years and then had the rug pulled out from under them wanted to commit suicide? Is it any wonder they turned to alcohol or drugs? Is it any wonder that they despaired? Is it any wonder that they gave up on politicians that that they had once respected, and then turned instead to a demagogue?

Constant Change


Americans, like Canadians, are living in a world that is changing faster than ever before. And that is change is constant. As a friend of mine always says, ‘Change is the only constant”.  And such constant change can be stressful.

There are all kinds of health problems out there. I know some of them too personally for my taste. People are obese.  It is astonishing how obese people are in the richest nation on earth. In Arizona where I spend a lot of time in recent years, we see it all the time. People have heart conditions. They have cancers. Yet, there is something harder to define. What Dr. Sanjay Gupta called the “real state of stress” in his HBO special.

And everyone wants a pill to solve their health problems. People want quick solutions to their problems. So do I of course. Americans take more drugs than the people of any other country on earth. And Canada is not far behind. Those drugs served a really useful purpose. They can save lives. They can ease pain. Yet, as Dr. Gupta pointed out, in the US  “50 people die every day from prescription pain killers!

Shown on Dr. Gupta’s special, Angela Glass was a mother in Victoria Texas. She knew that stress can be ugly. It can cause issues in every area of your life. Wherever you already have problems, stress can make them worse. Stress compounds the problem. Angela was prescribed a huge cocktail of drugs every day for her stress. She took pain medication–hydrocodone. She took other drugs for anxiety.  Things got worse. She lost a child. She took way more drugs than she was supposed to. She had suicidal thoughts. She considered taking all her pills and ending the pain once and for all. She couldn’t sleep. She was haunted. How many Americans and Canadians have been led down this path to drug dependence? How many Americans and Canadians have died as a result? In one year more Americans died from drug over doses than died in the entire Vietnam War! Since that happened in the United States, it has happened again!


Dr. Gupta believes that all this chronic stress, the pain which comes with the stress, and the desire to make that pain go away have combined to create a toxic brew that is destroying America and Canada. Many take medications even when they know it could take their lives.

This is dangerous stuff.

Epidemic of Despair  


When Dr. Sanjay Gupta, who besides being a physician is also a periodic commentator on CNN  first started looking at the deaths in the white middle class that included deaths by opioid overdose, suicide, cirrhosis of the liver, it felt a bit mysterious. He was struck by the numbers but did not really understand the causes. It took some time for him to piece things together.


He found an interesting article with an interesting title. This was “The Epidemic of Despair Among White Americans: Trends in the Leading Causes of Premature Death, 1999-2015” published by Elizabeth Stein, MD. MS, Keith P Gennuso, PhD, […] and Patrick Remington, MD MPH in the medical journal American Journal of Public Health. An epidemic of despair? That is very strong language? Is it justified? Gupta wanted to know. So did I.

Dr. Gupta wanted to know, ‘what causes those deaths of despair?’ That is an important question. He was not satisfied with the medical causes of death. He wanted to know ‘the cause of the cause.’ He, like me, thought that was a much more significant question. But this one is harder to tackle.

Why are people taking so many opioids?  Why are they becoming addicted? Part of it is overprescribing for which physicians are responsible. Why are so many people drinking to excess? Why are so many people dying of suicide. Is there a common cause of the cause?

As Neurosurgery Resident Kumar Vasudevan put it, “We are living in a time in which we are very, very good at treating diseases, we are less good and less proficient at understanding health.”  I would add, that many of us are reluctant to look at social causes, and, believe it or not, political causes. Is that possible?

As Dr. Gupta said, “deaths of despair seem to be a symptom of an underlying problem, rather than the problem itself.” Cyril Wecht believes that the underlying problem is that American society is increasingly stressed. Pressures make lives more and more difficult. Pressures of making a living, depersonalization, families breaking up, and what he calls the “robotization of society.”

But there were also things that happened on the side of medicine. The idea began to flourish that people should not have to suffer. If they suffer that was seen as a failure of medicine. There always seem to be simple solutions–write a prescription. Drugs can take care of any problem. But simple solutions are often the most dangerous. And prescriptions were one of them.

Of course there is more to it than this. Let’s look farther.

Why are so many young people killing themselves?


I think this problem I have been considering (the increasing rates of anxiety, depression, and self-harm among youth)  is related to a social phenomenon–the decline of the west, particularly the decline of our purported leader–the United States.


Nicholas Kristof and Sheryl WuDunn, in an article in the New York Times, described a school bus that Kristof regularly took in the days of his youth in the 1970s rural Oregon. In particular, they wrote about the Knapp family that also regularly took that same bus to school. The kids from that family were Farlan, Zealan, Rogena, Nathan and Keylan Knapp. Kristof and WuDunn suggest that this Knapp family, and others on that bus, were fairly typical of families at the time. Nothing really special–except that special things happened to them.  Here is what Kristof and WuDunn say happened to those typical kids:


“Yet today about one-quarter of the children on that No. 6 bus are dead, mostly from drugs, suicide, alcohol or reckless accidents. Of the five Knapp kids who had once been so cheery, Farlan died of liver failure from drink and drugs, Zealan burned to death in a house fire while passed out drunk, Rogena died from hepatitis linked to drug use and Nathan blew himself up cooking meth. Keylan survived partly because he spent 13 years in a state penitentiary.


Among other kids on the bus, Mike died from suicide, Steve from the aftermath of a motorcycle accident, Cindy from depression and a heart attack, Jeff from a daredevil car crash, Billy from diabetes in prison, Kevin from obesity-related ailments, Tim from a construction accident, Sue from undetermined causes. And then there’s Chris, who is presumed dead after years of alcoholism and homelessness. At least one more is in prison, and another is homeless.”


Kristof and WuDunn believe the causes are more complicated than those suggested by Dr. Friedman. In fact, they note, “Across America, working-class people — including many of our friends — are dying of despair. And we’re still blaming the wrong people”. Perhaps even Dr. Friedman was pointing in the wrong direction when looking for culprits (there is probably more than 1).


Here is what they have concluded:

 “We Americans are locked in political combat and focused on President Trump, but there is a cancer gnawing at the nation that predates Trump and is larger than him. Suicides are at their highest rate since World War II; one child in seven is living with a parent suffering from substance abuse; a baby is born every 15 minutes after prenatal exposure to opioids; America is slipping as a great power.”


In other words, Kristof and WuDunn, see these problems as part of American decline.  I see it as part of the decline of the west. As Haidt showed, this is not just an American problem. The same thing is happening in Canada.


Kimmapiiyipitssini: The Meaning of Empathy


The film Kimmapiiyipitssini: The Meaning of Empathy is film currently showing at Cinematheque and it should be widely viewed. It was produced by filmmaker Elle-Máijá Tailfeathers. It tells an important story. It is a story about life on an Indian Reserve in southern Alberta. I  drove by a couple of years ago on my way to Waterton Lakes National Park. (That also should be widely viewed).

The film tells the story of how that community has been ravaged by substance abuse and addictions and attempts to deal with that ugly fact by a new approach.  Instead of abstinence they are tying a new approach labeled as ‘Harm reduction.’ That just means they  abandon techniques that have failed over and over again and are  trying something new. It may be uncomfortable but can it possibly be worse than the robust failures of the old approach?


The significance of this film is not limited to Indian reserves; this issue is relevant around Canada. It affects poor people, the middle class and the rich. It is not the approach of Nancy Regan. Not Just ‘say No’. It would be nice if serous social problems could be solved by reciting a simple formula.


The substances include fentanyl, meth, Carfentanil or carfentanyl, heroin, and solvents. Interestingly carfentanyl has a quantitative potency approximately 10,000 times that of morphine and 100 times that of fentanyl. It seems like every couple of years something is invented that is worse than the drug of existing drug choice. No wonder we have such problems.


I know some of my friends were very depressed by what they saw. Who wouldn’t be?  Yet I would say things were not entirely hopeless. Grim but not hopeless. There was a hero in this story, physician Esther Tailfeathers, mother of the filmmaker, heroically I would say, without judgment is tackling the problems one person at a time. She tolerates the fact that her patients continue taking their drugs of choice. She has no magic. But she has quite diligence, energy, and most of all, empathy. She works daily on the front lines and offers help to addicts to kick their habits and prescribes suboxone as a substitute. Some criticize this approach by saying it merely substitutes one drug for another. Perhaps, but we have seen current techniques fail. I say, can this new approach be worse?


The harm reduction approach includes in some cases safe injection sites. Manitoba’s Department of Health when it was led by Steinbach’s own Kelvin Goertzen considered this new approach and rejected it. Alberta under the leadership of NDP premier Rachel Notely tried the new approach but it was rejected by the current United Conservative government led by Jason Kenney.

What I liked about the film was that by closely interviewing actual participants caught up in the epidemic of drug addictions on that reserve, I felt like I was there listening to the people. It was not an easy watch. How could it be?  But I felt like perhaps I could tell how they felt. Isn’t that what empathy is all about? Isn’t that important? Should we not consider their point of view?