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Saving a “Lost Generation”: The Need to Prevent Drug and Alcohol Abuse in Midlife

January 28, 2016

Blog post by Dr. Nora Volkow (NIDA Director) and Dr. George Koob (NIAAA Director) - originally posted on the Collaborative Research on Addiction web site
Image of bottles of alcohol with a figure in the background holding a drink

We have long expected to see increasing substance use in middle and later life with the aging of baby boomers—a demographic that traditionally had a more relaxed attitude to substance use.  A recent study funded by the National Institute on Aging reveals the unexpected enormity of the problem and its disastrous consequences for a generation of Americans.

In an article published last month in the Proceedings of the National Academy of Sciences, Princeton University economists Anne Case and Angus Deaton (who won the 2015 Nobel prize in economics for his research on poverty) identified an anomalous trend of increased all-cause mortality among white non-Hispanic, middle-aged (ages 45-55) Americans between 1999 and 2013 that appears mainly attributable to the devastating impact of substance use and emotional distress. Drug and alcohol poisonings and suicides accounted for most of the increased mortality; death from chronic liver diseases, which are associated with alcohol abuse, also rose in this population.

Deaths from these causes also increased in other age groups, but it was only in the 45-55 age group that they were sufficient to raise all-cause mortality. The increased mortality was most pronounced among those with lower educational attainment. In this day and age of increased longevity and advances in healthcare, any reversal of the overall downward trend in mortality and morbidity is alarming. Across the decade and a half of the study, most other age groups and ethnicities continued to see declines in mortality, as did European whites in the same age bracket. Had mortality continued to decline for non-Hispanic whites in this age bracket at the rate seen in the previous two decades, half a million deaths would have been avoided during this period.

The mortality increases paralleled increased self-reports of poor health, pain, psychological distress, and difficulties with activities of daily living (sitting, walking, shopping, socializing with friends) in this population—all of which may be linked to substance abuse. The time period of the study also corresponded to the escalating use of prescription opioids, which have been responsible for most of the drug poisonings. (More than 16,000 people died from prescription opioid overdoses in 2013.) This year, the Department of Health and Human Services and the White House announced multi-pronged initiatives to combat prescription opioid and heroin addiction and associated overdose deaths. But the PNAS study shows that the opioid epidemic may be part of a larger problem of increased distress among middle-aged whites. Stress and negative emotional states are well documented to contribute to the emergence of drug and alcohol use disorders, via a process of negative reinforcement.

A major driver of the opioid epidemic was the rise in opioid prescribing for chronic pain starting in the late 1990s. The associations between drug- and alcohol-related mortality, pain, and mental health led Case and Deaton to hypothesize that a number of contextual factors, including growing financial insecurity and declining economic prospects for baby boomers in the last two decades, may be involved. The resulting substance abuse and other mental and physical health problems may be leading, they fear, to a “lost generation” that may look forward to a less healthy as well as less prosperous future than their parents, and that may be a major drain on Medicare and disability funds in coming years.

Although we are accustomed to thinking about preventive interventions for youth, it is clearly necessary to also consider how we can prevent drug and alcohol abuse in middle age and older Americans.  These findings argue for greater integration of screening as well as drug and alcohol messaging in primary medicine. Primary care physicians are in a unique position not only to ask about substance use and track their patients’ use from visit to visit, but also to educate their patients about safe levels of alcohol use and the dangers of misuse of other substances. Since drug and alcohol use disorders often appear in tandem with pain and mental distress, providers may see these symptoms as warning signs, indicating a need to also pay attention to drug and alcohol misuse and not shy away from difficult conversations about these serious threats to those patients’ health and well-being.  

This page was last updated January 2016

Comments

Chronic Severe back pain and inability to secure pain medication

I am a retired nurse that was diagnosed with Degenerative Disc Disease 45 years ago. Have never had spinal surgery nor used opioids throughout this time span. I sought pain relief with the use of n-saids, which subsequently caused 3rd stage kidney disease, My P.C.P. referred me to a spine and pain control MD specialist. After radiologic diagnostics he informed me that my spine was inoperable and placed me on a contract for a daily regime of low dose opioids. Prior to that physically therapy was attempted, unsuccessfully! The opioid regime was quite successful, without untoward effects and I returned to a life of successful daily functioning. Since then I moved to a different state 8 months ago and have had a difficult time here in finding Doctor or clinic willing to prescribe (even under contract and with a letter of referral) pain medication to control my severe back pain. AND I have recently been diagnosed with Rheumatoid Arthritis which is very painful! They have gone as far as saying that they were not willing to risk their licenses by prescribing me pain medication! I know of a current trend of this with other people suffering such as I! While i realize there are people who abuse drugs, I feel the majority of us requiring pain control do not! And if we are denied relief from pain what are we to do I ask?--Suffer the with unbearable pain!? And could this denial for relief drive some to the streets for use of illegal drugs?

I am very sorry that you are

I am very sorry that you are having to endure these issues with pain and obtaining medication. It raises a very important concern: that in tackling the issues of prescription opioid abuse, the pendulum not swing too far the other way, such that patients with legitimate medical needs for these medications cannot get the help they require. Thank you for raising this point as part of the discussion.

Great response!

I'm sure this poor lady was comforted by your form letter which said NOTHING useful!

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The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.orgExternal link, please review our disclaimer.. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

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    Dr. Nora Volkow: Video Highlights

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