The United States is in the midst of a fatal drug epidemic. This study uses data from the Multiple Cause of Death Files to examine the extent to which increases in county-level drug mortality rates from 1999-2015 are due to “deaths of despair”, measured here by deterioration in medium-run economic conditions, or if they instead are more likely to reflect changes in the “drug environment” in ways that present differential risks to population subgroups. A primary finding is that counties experiencing relative economic decline did experience higher growth in drug mortality than those with more robust growth, but the relationship is weak and mostly explained by confounding factors. In the preferred estimates, changes in economic conditions account for less than one-tenth of the rise in drug and opioid-involved mortality rates.What they find instead is that the biggest factor influencing drug use in any community is the availability and cost of drugs.
This is just one study, but I would not be surprised if it is right. But not because I think the epidemic has nothing to do with “despair.” As we know, in our wealthy world economic troubles manifest largely in psychological terms, that is, a rise in the unemployment rate from 5% to 9% can make a lot more than 4% of the people miserable. So a whole community's sense that times are bad and the future is bleak might not show up very clearly in the raw economic numbers.
Take the paradigmatic case of the coal country in southern West Virginia and eastern Kentucky. These are poor areas, but they have always been poor. It's just that the industries they did have -- coal mining, manufacturing -- are rapidly declining. This makes their “medium-run economic conditions” only a little worse than they were, but it has a huge impact on the overall mood of those places. They are depressed and distressed, even if their median income is much higher than what we would consider a boom town in Nigeria or even Mexico.
Of course opiates are a big problem even in wealthy areas, which gets me to what “deaths of despair” would actually mean. I agree that the main cause of the epidemic is not economic hard times but the huge increase in the supply of the drugs. But why did people want them? Why was there, in economic terms, a huge unmet demand for opiates that changes in how doctors treat pain went a long way toward filling?
I don't think people take these drugs for fun. They take them because they are unhappy, stressed, and in pain. They are self-medicating conditions we could call anxious depression, chronic pain, chronic fatigue, or other such medical-sounding terms, but which I would be equally happy to call despair. I don't mean to say that many drug users don't have physical problems, from bad backs to chemical imbalances in their brains; I just think that when drug use runs rampant through whole communities, a broader understanding of the cause is called for.
If it is true that the main cause of the current opioid epidemic is increased supply, that makes the essential question very clear: why do people need drugs in the first place? And, is there anything we could do to make their lives better – less stressful, less painful, less depressing?