Opioid Overdose Deaths and Diseases of Despair

Data source: Virginia Department of Health. (Click for larger image.)

Everyone seems to agree that Virginia, like the rest of the nation, is in the grips of an epidemic of opioid overdoses. Virginia Department of Health (VDH) data show that the number of overdose deaths attributable to Fentanyl and/or heroin and to prescription opioids has increased from 637 in 2011 to 1,426 last year. The dominant trope in reporting and commentary on this surge is to refer to it as a “disease of despair” connected to deteriorating social and economic conditions. To add insight, VDH breaks down not only the number of overdoses by locality on its data portal, but so-called “social determinants of health” such as the percentage of children in poverty.

“On the surface, it appears to be the opioid epidemic, but where you look at the opioid epidemic or addiction in general, it’s really a disease of despair,” said State Health Commissioner M. Norman Oliver at a Virginia Board of Health meeting last month. “What drives it is the lack of jobs, the lack of affordable housing, the lack of transportation …”

When the opioid epidemic first attracted media attention a few years ago, the disease-of-despair label seemed to make sense. While overdoses were more frequent as measured by absolute numbers in Virginia’s metropolitan areas, as a percentage of the population, overdoses were higher in many rural counties — particularly  in poor Appalachian counties — Tazewell, Russell, Washington, and Dickenson most prominently — where the traditional coal mining/mill town economy was disintegrating.

We’ve all heard the narrative. Poor, hopeless, rural Virginians would get hooked on prescription pain killers. When they couldn’t get prescription drugs, they moved on to heroin. Next thing you know, the heroin was laced with Fentanyl and addicts began dropping like flies. Meanwhile, drug overdoses went hand-in-hand with an increase in suicides and other self-destructive behavior.

I’m not suggesting from my cursory examination of the data that the conventional wisdom is wrong. But I would suggest that the story is more complicated — as Oliver acknowledged during the last month’s VHB meeting. “What we’re dealing with is an addiction epidemic, not an opioid epidemic,” he said. “We may get a handle on prescription opioids just to see meth and other things take their place.”

Indeed, it appears that the alarm over prescription opioids is having a dampening effect. The surge of opioid-related overdoses between 2011 and 2017 was driven almost entirely by Fentanyl and heroin. The number of prescription-related deaths increased by only 12 over that six-year period. The devastating increase in overdose deaths resulted mainly from the introduction of the super-powerful Fentanyl into the illegal drug marketplace. Fentanyl/heroin overdose deaths increased by 777 over the same period.

However, statewide averages obscure what’s happening at the local level, and local trends diverged remarkably. The number of drug overdoses actually declined in 24 localities over the six years covered in the VDH database. Every one of those localities (except one small city, Buena Vista) was a poor, rural county in Southside, Southwest or Western Virginia. The most marked drops occurred in the “despair-central” counties of Tazewell, Russell, Washington, and Dickenson.

Another 20 Virginia jurisdictions showed no change. Other than the small cities of Staunton and Williamsburg, all were predominantly rural counties.

Where, then, did the surge in overdoses occur? Check the table atop this post. In raw numbers, Fairfax County, Richmond, Henrico County and Virginia Beach topped the list. The increase in Richmond was particularly striking, given its smaller population than other jurisdictions atop the list. One cannot help but wonder if the growing number of deaths in neighboring Henrico and Chesterfield is related. Both counties have seen an influx of poor households from the city in recent decades.

The localities in the table are not seeing a commensurate surge in prescription overdoses, which suggests that the overdose epidemic stems from some other cause than the painkiller-to-heroin-to-Fentanyl pathway. An alternate theory: The introduction of Fentanyl is primarily affecting populations where heroin addiction has long been a deeply rooted problem.

It is worth noting that the localities seeing the biggest increases are not economic backwaters. They are in prosperous metropolitan areas. Deaths of despair? Are overdose victims people in poor neighborhoods who couldn’t find mass transit connections to jobs? I’m dubious. In my observation, drug and alcohol addiction strikes all levels of society indiscriminately.

Some people are inclined to blame all of society’s ills on one form of inequality or another. I tend to think the story is a lot more complicated. One way or another, the subject warrants a deeper dive than I manage in a morning’s work on this blog.

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14 responses to “Opioid Overdose Deaths and Diseases of Despair

  1. Fairfax: “What drives it is the lack of jobs, the lack of affordable housing, the lack of transportation …”. We have been writing about this here on Bacon’s Rebellion for years. Rotten Government on all levels is driving this despair.

  2. Of course – if we haven’t already – we’ll soon have the question which is – “If Virginia has a historically low unemployment rate of 2.9% and NoVa at 2.3%, how can there be “despair”?

    And the answer is – there are two Americas – and behind those low numbers are, in fact, millions of people who are in economic distress and engage in unhealthy and illegal behaviors that almost never improve their prospects.

    And the legitimate question is – is this a criminal justice issue?

    Because that’s how we have dealt with this for some time – and only of late are we re-examining it … and yes … low and behold – the issue is in our urban areas as well as our rural areas.

    Some folks say we cannot fix this by drawing people into the criminal justice system while others say we can’t fix it anyhow so locking them up protects the rest of us from them.

    My primary view is that we still have a two-tier system. If you are rich and have “despair” and abuse drugs – you stay rich and keep on going – if you are poor – things get even worse AND there IS a HIGH PRICE to taxpayers whether we lock them up or treat their problem as a health issue.

    So a cynic might say that if your “despair” is not due to financial problems – you deserve to not be destroyed by the criminal justice system but if your “despair” is because you are in the bottom tiers of the economic ladder – then bad on you – we’re going to “fix” you even better (sic)!

  3. The government and the medical community have really clamped down on prescription opioid use. Gone are the prescription mills. New systems track patients trying to hop from doctor to doctor getting multiple prescriptions. Many doctors of family medicine won’t prescribe opioids at all with a visit to a pain specialist first.

    The prescription problem is under control. Not so the illegal drug problem.

  4. Two Americas.

    Many European and Asian nations have and have had very split societies with one or more level of “haves,” have some” and “have nots.” Germany, for example, has had a lower class of foreign workers for decades. Japan has historically had a Korean underclass. And even, Sweden is rapidly developing a large underclass of refugees, many from Islamic nations.

    While the great racial split in the United States has changed (at least for many blacks), we continue to have many African Americans trapped in poverty as well as so-called “poor white trash.” And now we are setting ourselves up to have a massive underclass of recent illegal immigrants who will be facing an economy where many low-skilled jobs are increasingly automated.

    Something in the Bible. The poor you will always have with you. I think the split in the United States will become greater over time.

  5. The distribution of opioid deaths in VDH’s data portal does seem to differ from some of the common story lines about opioids. Warren, Culpeper and other exurban counties have the highest overdose death rates per capita rather than more rural counties.

    • If I had the time, I’d map death rates. Perhaps I’ll get to it one day. Better yet, maybe Hamilton, who is far better at this kind of analysis than I am, will give it a shot.

      I think you’re on to something with the observation about high death rates in Washington exurban counties. Could there be a correlation between deaths of despair and long commutes into Northern Virginia? Or are long-time inhabitants being displaced by more affluent NoVa workers seeking more affordable real estate?

      • The VDH data portal has a nice map of the death rates at the bottom of the page but I would like to see a map of combined death rates for all types of opioids.

        Long commutes could certainly be a factor, people often move out to exurban counties to find cheaper housing, so they may also be financially stressed. The exurban counties also have higher proportions of the age ranges most likely to overdose (35-54). More rural counties often have an older age distribution which may explain lower and declining mortality rates.

      • Gentleman,

        With regard to this hell on earth, that our governments and related institutions have been cooking up here in America for decades, we here have seen only the start of this despair. Check out what is happening in California, and many other places throughout the country, like Chicago or Portland, too:


        And while you are at it, throw in Charlottesville, Virginia.

  6. I think if a link between drug use and commutes is established, all heck will break loose.

    Call me a skeptic but I can be and am convinceable with good data.

    Clearly, though when we talk about “despair”, we’re talking about people who have poor educations, poor job prospects, perhaps a criminal record – and pretty much out of options for a reasonable and comfortable life.

    I think it’s hard to point to one single thing as the overall biggest cause.

    Some people go on drugs when they have everything going for them – they’re rich and have little wants financially.. but they still become addicts.

    This is an area where professionals in the field have much better understanding and knowledge than lay folks.

    So to end on a constructive note – I like Jim’s idea of getting someone who has good knowledge of the issue – even perhaps a VDH person or a retired VDH person or someone who works or has worked in a county Social Service office – to give their perspective. It would be informative and perhaps help dispel some misconceptions that some of us – including me , may have.

  7. I have to say – after actually visiting the VDH data portal – someone over there has done a bang up job with the data and presentation of the data on the web


    Second.. I got curious about my own county Spotsylvania which registered as a high death county and sure enough there were some deaths – 15 in fact.

    Now , we do have about 125,000 folks living here and 15 is not a wonderful number but I’m betting we had way more deaths from other things like cancer and heart disease … including among commuters!!!

    So I go back to how so much more data is now available and how when we focus on it – we need to also try to maintain context.

    I’m not diminishing the opioid nor drug problem – it’s a huge problem – both public health wise and criminal-justice wise but smoking and obesity are major competitors also.

    so here’s a chart that also shows deaths:

    • Larry, you are close to achieving wisdom. You understand that different health threats pose different levels of risk to the public. Chronic lung disease, as you rightly point out, causes many more deaths per 100,000 than opioid addiction. Now, I ask you, how many additional deaths would be caused by Dominion Energy’s proposed bury-in-place plan as opposed to the transport-and-bury alternative. As I asked in my recent post, how much risk mitigation does an extra $4 billion buy us? I don’t know the answer, but I would conjecture that the lives saved for that investment will be vanishingly small.

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