The rate of “deaths of despair” is slowly declining, a new report said, but they are still more prevalent in Appalachia than in the rest of the country.
Deaths of despair – those associated with drug overdoses, alcohol, and suicide – had been on the rise nationwide throughout the Covid-19 pandemic, according to the research done for the Appalachian Regional Commission (ARC).
Rates across the country and in Appalachia have fallen about 5%, almost to pre-pandemic levels, said Michael Meit, director for the Center for Rural Health and Research at East Tennessee State University (ETSU) and a co-author of the report. But Appalachians still die from those causes at a higher rate than the rest of the country, he said.
The cause of the gap is complicated, Meit explained.
“I think there are a lot of complexities to it, and I don’t know if we know all of the answers,” Meit said in an interview with the Daily Yonder. “What we do know is that a big driver of that is overdose mortality. When we see a big change in overdose mortality, that’s going to drive all of the deaths of despair. We did see this decline from 2017 to 2018 that was driven by reduced deaths due to overdose mortality. During Covid, that spiked for [a number of] reasons – it was isolation, it was lack of continuity of care, or people unable to access peer support.”
The study is the latest update to research started in 2017. At that time, Appalachian mortality from overdose, alcohol, and suicide was 44% higher than it was in the rest of the country. In the following years, the gap began to narrow, but still, Appalachian deaths of despair remained 33% higher than those in the rest of the country.
By 2019, there were 76.1 deaths of despair per every 100,000 Appalachians between the ages of 15 and 64, compared to 56.2 deaths per 100,000 in the non-Appalachian U.S. During the Covid-19 pandemic, those deaths rose nationwide, but they rose more in Appalachia (42%) than in the rest of the country (33%).
“As a result, in 2021, the diseases of despair mortality rate was 43% higher in the Appalachian Region than in the non-Appalachian U.S.,” the latest report stated. “In 2023, both the Appalachian Region and the non-Appalachian U.S. experienced an approximately 5% decrease in the mortality rate of diseases of despair, compared to the rates in 2022.”
Across Appalachia, deaths of despair fell from 105 deaths per 100,000 in 2022 to 100 deaths per 100,000 in 2023. In the non-Appalachia U.S., the rate fell from 76.4 deaths per 100,000 to 73 deaths per 100,000 in 2023.
Despite the declines, rates […] are still higher than they were pre-pandemic, Meit said.
While overdose is a primary driver of the deaths-of-despair gap, both deaths due to alcohol and deaths due to suicide are also higher in Appalachia than in the rest of the country.
In 2023, there 10,323 deaths due to overdose, 3,568 attributed to suicide, and 2,812 attributed to alcoholic liver disease/cirrhosis, the study found. Overdose mortality was 50% higher in Appalachia than the rest of the country, with 64.1 deaths per 100,000 attributed to overdoses in Appalachia, and 42.7 deaths per 100,000 in non-Appalachia. The study found that the suicide rate in Appalachia was 22% higher and that liver disease mortality was 13% higher.
One of the age groups most impacted by the deaths of despair, Meit said, was Millennials, or those born between 1981 and 1999. It’s a trend that is impacting adults of that generation across the country. According to a report by Trust for America’s Health, the largest number of deaths from overdoses, alcohol, and suicide in the 25- to 44-year-old demographic has steadily increased since 2017.
“Increases in alcohol, drug, and suicide deaths have affected all age groups and all communities, but the impact on people in their 20s and early 30s has been especially pronounced,” the Trust for America’s Health report stated. In particular, the number of drug deaths among young adults has increased by 400% during the last two decades, in large part fueled by the opioid crisis.”
According to the ETSU study, the diseases of despair mortality rate for those 25-44 was 118.5 deaths per 100,000 in Appalachia, 39% higher than in the non-Appalachian U.S. (85.5 deaths per 100,000). Their deaths could impact generations to come, Meit said.
“Those are people who are in their prime child-rearing years, so we need to be worried about the impacts on our children and adverse childhood experiences,” he said. “These are also people in their prime working years, so when we talk about economic opportunity and economic development, that’s a resource that we’re losing to revitalize the economies of our communities, too. There are economic consequences. We need to be concerned about the fact that it’s people in that age bracket that are most impacted.”
In response, the Appalachian Regional Commission awarded nearly $11.5 million in 2023 to nearly 40 projects across the region to address the impact of substance use disorder. Part of ARC’s “Investments Supporting Partnerships in Recovery Ecosystems ” initiative, the projects invested in projects that aimed to strengthen addiction recovery in 127 counties by funding programs in nine states—Kentucky, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia, and West Virginia
Those programs are helping, Meit said, but at a more local level.
“There are a lot of success stories that emerged from that program,” he said. “You don’t necessarily see a region-wide impact, but you see really strong community-based efforts that impact those communities. And as you reduce numbers in any given community, that has a broader impact across the region.”
Those programs and rural healthcare across the country face an uphill battle, though, as funding for them begins to dwindle. Many programs intended to address deaths of despair are paid for by Medicare, Meit said, and changes in federal spending will have an outsized effect on the ability to pay for those programs, and even health care facilities themselves.
“The estimates are that the Medicaid cuts will total about $1 trillion, and that between $137 billion and $155 billion of that will be cuts to rural facilities,” Meit said. “But that’s also rural substance use treatment, home health, long-term care, anything that is paid with Medicaid dollars. The rug is about to be pulled out.”
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