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Deaths of Despair and Building a National Resilience Strategy

Auerbach, John, MBA; Miller, Benjamin, F., PsyD

Journal of Public Health Management and Practice: July/August 2018 - Volume 24 - Issue 4 - p 297–300
doi: 10.1097/PHH.0000000000000835

Trust for America's Health, Washington, District of Columbia (Mr Auerbach); Well Being Trust, Oakland, California (Dr Miller).

Correspondence: John Auerbach, MBA, Trust for America's Health, 1730 M St, NW, Ste 900, Washington, DC 20036 (

The authors declare no conflicts of interest.

The United States is facing a triple set of epidemics—more than 1 million Americans have died from drug overdoses, alcohol, and suicides between 2006 and 2015.1 Life expectancy in the country decreased 2 years in a row.2

According to the most recent data, in 2016, 142 000 Americans, the highest number ever recorded, died from alcohol- and drug-induced fatalities and suicide—an average of 1 every 4 minutes.3 * For context, deaths from these 3 causes are nearly identical in number as those who died in 2016 from stroke, the fifth leading cause of death in United States, and are greater than the number of Americans who died in all US wars since 1950 combined (Figure).4 , 5 ,



For the second year in a row, alcohol, drug, and suicide deaths also increased at a record pace, with an 11% increase—or more than 14 000 additional deaths—between 2015 and 2016 and a 7% increase from 2014 to 2015. In comparison, the death rate of heart disease and cancer, the leading causes of death in the United States, declined between 2015 and 2016, as they have over the previous decade as well.§

Sadly, no part of our country is immune to these devastating deaths. While drug overdoses were still highest among whites in 2016, there were disproportionately large increases in drug deaths among racial/ethnic minority groups, particularly among black Americans. In the previous decade, blacks had relatively low drug overdose rates—averaging 35% lower than whites between 2006 and 2015. However, between 2015 and 2016, blacks experienced an alarming increase—of 39%—in drug-related deaths.

Deaths from synthetic opioids—including fentanyl and carfentanil—doubled from 2015 to 2016, from 9600 to 19 400, and was the driving force for the extraordinary increase in drug deaths. (Alcohol, other types of drugs, and suicide deaths also increased but by a much lower amount.) The lethality of these drugs puts users at extremely high risk—compared with heroin, fentanyl is 50 times more potent and carfentanil is 5000 times more potent than heroin.6

In November, Trust for America's Health (TFAH) and Well Being Trust (WBT) issued projections in the Pain in the Nation: The Drug, Alcohol and Suicide Epidemics and the Need for a National Resilience Strategy report, which found that if drug, alcohol, and suicide deaths had continued on the trajectory of the past decade, they could reach 1.6 million over the next decade.

However, our new analysis, released just last month, finds that the substantial rise in deaths in 2016 puts the country past the “worst-case scenario” projection trajectory. If deaths continue to grow at the similar rates as from 2015 to 2016, deaths could top more than 2 million in the coming decade. This would mean more than 287 700 individuals could die from these 3 causes in the year 2025, double the current number who died in 2016.7

These trends should be a wake-up call that there is a serious well-being crisis in this country. In stark terms, they are signals of serious underlying concerns facing too many Americans—about pain, despair, disconnection, and lack of opportunity—and the urgent need to address them. And let us not forget that projections are indeed just that, projections, as we can prevent these avoidable deaths through thoughtful planning and strategy.

Both TFAH and WBT have called for the urgent development of a national strategy to improve resilience in the United States. Quite simply, if action is not taken, these trends could likely become significantly worse.

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A National Resilience Strategy

The rapid rise of these epidemics over the past 15 years constitutes 3 of the most serious public health crises of this century. The life-and-death consequences of drug and alcohol misuse and suicide have reached urgent levels in many communities. In addition, wide-scale substance misuse and insufficient attention to mental health disorders have broad impact. The added recent dramatic increase of illicit opioids—heroin and its blending with the more potent fentanyl and even more potent carfentanil—has made the immediate situation even more dire and complicated. While the crises have received much attention, the actions that have been taken to date are severely inadequate.

The country has long struggled with effective approaches to promoting positive mental health and health behaviors to more effectively manage pain. The confluence of “despair deaths” is directly related to pervasive issues with how the country views and manages mental health, pain, and despair—and without better strategies that focus on preventing problems and providing effective support, services, and treatment, the trends are likely to be perpetuated and get worse.

Much of the response to date has been focused on reacting to the acute emergencies of overdoses, insufficient treatment availability and options, and limiting the supply of opioids. While positive steps, these programmatic steps, in and of themselves, are insufficient. The nation's response must go beyond these to systemically include the following:

  • Heightened monitoring or surveillance of these issues; improving our ability to track problems and target response activities. Such monitoring should include drug use patterns, such as identifying trends in prescription drug misuse, heroin, fentanyl, and carfentanil increases in communities—and related harms such as hepatitis C and HIV infection.
  • Evidence-based community prevention programs that can be scaled and expanded to benefit local areas throughout the country and which support best practice, multisector partnerships that leverage the leadership, expertise, and resources within a community to support a comprehensive strategy.
  • Expert networks that can provide advice and technical assistance so that effective programs are implemented for maximum impact.

It is imperative that we as a nation improve pain treatment and management practices, including, but not limited to, responsible prescribing of prescription opioids (Table 1). At the same time, reducing the harms caused by overdoses and misuse and treating substance use disorders as a public health issue first are necessary (Table 2).





Layering on top of these plans—because preventing excessive drinking, alcohol use disorders, and opioid misuse is an important strategy for reducing suicides—to have a true National Resilience Strategy, the nation must focus on preventing suicides by supporting a cultural shift that focuses on providing help to individuals, especially when experiencing trauma, distress, or severe circumstances. Some leading strategies are as follows:

  • The National Violent Death Report System should be expanded to every state to allow for better tracking of suicide patterns and risks to develop stronger, targeted prevention strategies.
  • Building statewide suicide prevention plans that focus on creating effective support systems within key institutions and training those in positions that have high contact with tweens, teens, and young adults (ie, educators, community and faith leaders, human resource, and social service providers, etc). Special focus should be dedicated to school-based efforts and those that support veterans, Native American/Alaska Native, LGBT, and other higher-risk communities.
  • Suicide risk identification training for medical professionals and increasing access to integrated mental health services in strategic places such as primary care.9
  • Limiting access to “hot spots” and lethal means for suicide since most suicides are carried out within a short time of having suicidal thoughts and risk goes down if means are not available. This includes promoting safety within communities (bridges, building access, etc) and promoting firearm safety policies, especially for those at risk, including safe storage, child access prevention, gun violence protective orders, and background reporting/checks for mental illness and other risks.

To address the deaths from despair—and this will help reduce all of them—mental health and substance use services must be expanded and modernized. With only around 1 in 10 people receiving the recommended treatment of substance use disorders and 4 of 10 receiving the recommended treatment of mental illness,9 there is an urgent need to expand the availability of behavioral health services. The gaps are particularly acute in rural and lower-income areas.

In addition, there is a need to expand the use of modern best practices for treatment in line with research about what are most effective upstream interventions (including being able to provide different forms of treatment, durations, and scopes that match the needs and conditions of individual patients) (Table 3).



The nation should support evidence-based policies and programs that reduce risks for substance misuse, suicide, and other harms and promote protective factors such as safe, secure families, homes, and communities; life and coping skills; and social-emotional development. If we do this, we shall go a long way to reducing the deaths from despair.

In addition, policies should support multisector collaborative partnerships that provide support and leadership for comprehensive approaches to problems, such as the opioid, alcohol, and suicide crises, which impact the whole community.

These partnerships provide the infrastructure to leverage the expertise, resources, leadership, and capabilities of a broad range of partners—health care and hospitals, universities and schools, businesses, community and faith groups, and other organizations—across a community for stronger collective impact. And they are key for being able to scale and sustain policies and programs to address the opioid, alcohol, and suicide epidemics—and to also focus on promoting prevention-focused efforts on an ongoing basis.

Expert networks can provide guidance on evidence-based approaches that best fit a local area's needs and technical assistance for effective implementation and evaluation of the effort.

And, research shows early childhood strategies—including high-quality home visiting programs; evidence-based parent education and support initiatives; high-quality child care and early childhood education; and services that provide support to transition from early childhood programs to elementary school—will pay huge dividends.

The nation should also modernize the child welfare system and focus on multigenerational care, including supporting the ability of grandparents and other relatives to provide care for children when possible, and appropriate and comprehensive supports and case manager approaches for children in foster care system.

To additionally focus on school-aged tween/teen strategies, the nation should support healthy school climates for all individuals; evidence-based social-emotional learning and life and coping skill programs; widespread use of modern evidence-based substance misuse prevention programs; expanding access to school counselors and mental health personnel; and school-based suicide prevention plans including training for personnel.

The data paint a stark picture. With the dramatic increase in death rates across racial minorities, the country is definitively on track for the worst possible case scenario.

But, thankfully, there is a path forward. All across this nation, communities are rising up to address these issues that take lives all too soon. The resources and additional expertise needed to prevent more deaths should be provided as soon as possible—and the nation must come together to support and implement a National Resilience Strategy.

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1. Hohmann J. The Daily 202: Trump over performed the most in counties with the highest drug, alcohol and suicide mortality rates. Washington Post. December 9, 2016. Accessed September 2017.
2. Kochanek KD, Murphy S, Xu J, Arias E. Mortality in the United States, 2016. Hyattsville, MD: National Center for Health Statistics; 2017. NCHS Data Brief No. 293. Accessed May 6, 2018.
3. Centers for Disease Control and Prevention, National Center for Health Statistics. Multiple cause of death 1999-2016 on CDC WONDER Online Database, released December 2017. Accessed May 6, 2018.
4. US Departments of Veterans Affairs. America's Wars fact sheet. Published May 2017. Accessed February 7, 2018.
5. US Department of Defense. DOD Casualty Report. Accessed February 7, 2018.
6. US Drug Enforcement Agency. DEA issues carfentanil warning to police and public. Published September 22, 2016. Accessed May 6, 2018.
7. Trust for America's Health. Pain in the nation: the drug, alcohol and suicide epidemics and the need for a National Resilience Strategy. Published November 2017. Accessed May 6, 2018.
8. Miller BF, Ross KM, Davis M, Melek SP, Kathol R, Gordon P. Payment reform in the patient-centered medical home: enabling and sustaining integrated behavioral health care. Am Psychol. 2017;72(1):55–68.
    9. Substance Abuse and Mental Health Services Administration. Results from the 2014 National Survey on Drug Use and Health: Mental Health Findings Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015. NSDUH Series H-50, HHS Publication No. (SMA) 15-4927. Accessed October 27, 2015.
    10. Miller BF, Petterson S, Burke BT, Phillips RL Jr, Green LA. Proximity of providers: colocating behavioral health and primary care and the prospects for an integrated workforce. Am Psychol. 2014;69(4):443–451.

      * Data are from the Multiple Cause of Death Files, 1999-2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. For additional information on TFAH's methodology, see the Appendix on page 13 of the report available at:
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      † According to CDC Multiple Cause of Death data, in 2016, 635 260 Americans died from heart disease; 598 038 died from cancer; 154 596 died from chronic lower respiratory diseases; 161 374 died from accidents; 142 142 died from stroke; and 141 963 died from alcohol, drugs, and suicide.
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      ‡ According to the US Departments of Veterans Affairs and Defense, 102 125 Americans died in war since 1950—including 36 574 in the Korean War, 58 220 in the Vietnam War, 383 in Desert Shield/Desert Storm, and 6948 in the Global War on Terror (through February 7, 2018).
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      § According to CDC Multiple Cause of Death data, the death rate from heart disease and cancer was 391.4 per 100 000 in 2007, 382.6 per 100 000 in 2015, and 381.7 per 100 000 in 2016.
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      ¶ Centers for Disease Control and Prevention Multiple Cause of Death data show that, between 2006 and 2016, blacks averaged 10.0 drug deaths per 100 000 and whites averaged 15.5 drug death per 100 000.
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