Deaths of Despair

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Dr. Bloom has written eloquently and often about individuals with chronic pain, caught-up in opioid guidelines designed to reduce the deaths due to drug overdoses. But many, if not most of those deaths, are due to despair. Wouldn’t it be better to treat this problem and ease the guidelines on individuals in chronic pain that are “collateral damage?”

As I said, Dr. Bloom has spoken up for chronic pain patients, the "collateral" damage in our opioid war; and the States and Federal governments are close to a settlement with the purveyors of opioids unless of course, you count the drug cartels. With the "low-hanging" fruit addressed that leaves the hard work of understanding the forces behind these deaths, deaths of despair when dreams are crushed and hope evaporates.

Deaths of despair defined as “mortality resulting from suicide, drug overdose, and alcohol-related liver disease” are increasingly problematic – COVID-19 enhanced that despair. Easy access to handguns, alcohol, opioids, prescribed, diverted, or illicit increases the likelihood of these despairs. Despair makes no racial or gender distinctions, nor is it solely the problem of the urban centers or rural areas. The media offers its narrative of how these deaths arise. A new study looks at what front-line workers, healthcare’s “boots on the ground,” perceive to be the underlying issues.

The Study

The analysis published in JAMA Network Open is qualitative; there are no p values to interfere with their message. Using diagnostic coding, use for billing within the Highmark system in Pennsylvania, the researchers identified hotspots of “a diagnosis related to alcohol or substance use, and suicide ideation or behavior.” They found a hotspot of despair near Pennsylvania’s capital, Harrisburg, in Dauphin and Lebanon counties, recruiting focus groups from healthcare workers in these areas that worked with those at risk for deaths of despair. 

The conversation with these workers recorded from September 2019 to January 2020 underwent “thematic analysis” – they abstracted the core concerns of these first-hand providers. These were the words of the doers, [1] not the academician theorists or the administrator searching for funding opportunities. If nothing else, we owe it to them to listen.

  • Financial distress – “Cause it’s more expensive to eat than to get high. And the loss of life, they just don’t care anymore. They’d rather be high and happy than not high and sad.”
  • Lack of infrastructure and access to fundamental services – “there’s just not the kind of benefits with jobs, even full-time jobs, as there used to be even 10 years ago.” “We don’t have trade schools for kids like we used to….They need a trade, or GED… or they drift.”
  • Deteriorating sense of community, a decline in civic trust! – “If you’d ask my next-door neighbor my son’s name, what he wanted to do, where he wanted to go, they’d have no idea. Because we don’t talk to each other or help each other like we used to.”
  • Dysfunction and fragmentation in family life – “Increasingly there’s less and less family support. Not even to mention friend support. … a lot of times kids are raising themselves instead of parents.”

My modest disclaimer

I know that these things are true because I was one of the physicians in Lebanon County at the end of my clinical career. If anything, they have understated the problem. I thought a twenty-five-year career in the Tri-state area made me relatively urbane; Lebanon taught me how parochial my views and understanding really were. This is the home of the Amish and the Mennonites and is more ethnically and racially diverse than you might anticipate. This is family and church country; if they are experiencing the breakdown of the family, that is a very real problem. 

For many years this area was home to small manufacturers employing tens and maybe a hundred or so workers making widgets to be assembled elsewhere into bigger things. Globalization took their jobs and outsourced them so that we could pay less for more. Jobs that supply a living wage and a sense of providing for yourself or your family are part of the community, especially in Lebanon and Dauphin counties. Perhaps when you think about the funding for infrastructure, you might see that it is more than bridges, roads, and tunnels—ditto for schools that do not prepare you to live your life. 

"Despair is something that is an indictment of the way that we have organized our society rather than a personal failing or an individuated sense of despair that somebody may feel. People are responding to objectively worsening material circumstances in their lives.”

Daniel George, associate professor and researcher, Penn State College of Medicine

You can’t ignore a cry for help when it is right in front of you, but it is easier not to notice when it is presented as opioid overdose deaths; after all, you know what kind of people are using opioids. Or do you? 


[1] The group included 44 women, 16 men, two-thirds white, 25% Black, 5% Hispanic, predominantly working in a rural area. Seven came from an urban center, but Harrisburg has a population of 50,000. Bedford-Stuyvesant, one neighborhood in New York City, has a population three times that. 


Source: Perceptions of Diseases of Despair by Members of Rural and Urban High-Prevalence Communities A Qualitative Study JAMA Network Open DOI: 10.1001/jamanetworkopen.2021.18134