Mortality Rates for Substance Abuse, Self-Harm On the Rise

Laura Dwyer-Lindgren, PhD

Mortality rates and trends in the United States due to drug use disorders have increased nationally since 1980, and while rates due to alcohol use disorders and self-harm have decreased, they are on an upward trend since 2000.

These rates, including those due to interpersonal violence, also vary drastically in terms of geography, down to the county level, according to an analysis of data from 1980 to 2014.

The analysis, led by Laura Dwyer-Lindgren, PhD, an assistant professor at the Institute for Health Metrics and Evaluation, examined substance abuse disorders, including those with drugs and alcohol—which accounted for nearly 4% of all deaths in the United States in 2015—as well as interpersonal violence and self-harm in order to identify trends to inform prevention and therapeutic efforts.

“Substance use disorders and intentional injury are responsible for a significant health burden in the United States, particularly among young and middle-aged adults,” Dywer-Lindgren and colleagues wrote. “Indeed, among people aged 15 to 49 years in the United States, self-harm, drug use disorders, and interpersonal violence are the first, second, and fifth leading causes of death; combined, substance use disorders and intentional injuries are responsible for nearly one-third of all deaths in this age group.”

The findings revealed that mortality rates due to drug use disorders increased not only nationally, but in 99.8% of counties over the 34 years examined, although the increases varied wildly—from 8.2% to 8,369.7%. All told, there were 2,848,768 deaths examined, of which 7.94% (n = 256,432) were attributed to alcohol use disorders, 19.04% (n = 542,501) to drug use disorders, 45.25% (n = 1,289,086) to self-harm, and 26.70% (n = 760,749) to interpersonal violence.

For drug use disorders, the national age-standardized rate of mortality in 2014 was 10.4 per 100,000 persons (95% Uncertainty Interval [UI], 9.7 to 10.9), an overall increase of 618.3% (95% UI, 526.8% to 648.3%) since 1980. In the final 14 years of the analysis, the increase was 112.4% (95% UI, 98.4% to 125.7%).

"Our study is primarily descriptive in nature, and does not necessarily point to any 1 prevention or treatment choice," Dywer-Lindgren told MD Magazine. "We hope that it will help highlight where there are particularly pressing needs, and where there are concerning trends—both for substance use disorders as well as for intentional injuries—and that clinicians will be able to use this as an additional source of information about the communities they serve."

Age-standardized mortality rates varied from 1.6 to 57.1 per 100,000 at the county level. Relative to the rest of the country, counties near the border of Kentucky and West Virginia, as well as specific counties within New Mexico, Alabama, Indiana, Tennessee, and Virginia had higher rates of mortality that were in the top 1%—greater than 32.3 deaths per 100,000 persons.

In 1980, counties in the 90^th percentile of mortality rates had rates of 1.1 deaths per 100,000, with the threshold jumping to 17.0 in 2014 (absolute difference, 12.9 deaths per 100,000; relative difference, 4.2-fold).

As the opioid epidemic rages on in the United States, the immediate reaction is to point to the high levels of dependence to these pain relief therapies. Multiple studies have shown that overdose rates are on the rise, but Dywer-Lindgren warned that opioids are only—while a big piece—part of the puzzle.

"We did not look at how this breaks down by particular types of drugs, but many other studies have documented the massive increase in opioid deaths specifically over this period in the US," she said. "Opioids are not the whole story, but they are certainly a very important part of what is going on both nationally and at the county level."

Comparatively, the mortality rate for alcohol use disorders was 2.8 per 100,000 (95% UI, 2.7 to 3.0) in 2014, decreasing 8.1% from 1980 to 2014 (95% UI, —0.5% to 21.1%), although the rate increased 3.2% (95% UI, –3.9% to 10.0%) and 65.4% of counties experienced increases (statistically significant in 26.8%). These counties were predominately located in the northern and western US.

At the county level, mortality rates for alcohol use disorder varied from 0.6 to 38.8 per 100,000. Counties in Wisconsin, the Dakotas, Nebraska, Montana, Arizona, Utah, and Alaska had especially high rates (>12.9 deaths per 100,000).

In regard to self-harm and interpersonal violence, the national mortality rates were 13.9 per 100,000 and 5.7 per 100,000, respectively, equating to respective decreases of 6.0% (95% UI, 1.0% to 11.2%) and 34.6% (95% UI, 31.0% to 37.4%). Although, from 2000 to 2014, the national mortality rate due to self-harm increased 11.0% (95% UI, 6.4% to 15.7%).

The authors noted that “in terms of geographic variation, deaths from self-harm were particularly high in regions of the Western United States with high rates of firearm availability and relatively low population density. Further action is required to reverse these recent increases and reduce the substantial health and social burden imposed by self-harm.”

The counties with the highest self-harm mortality rates (>34.2 deaths per 100,000) were located in Alaska, Nevada, South Dakota, Utah, New Mexico, Arizona, Montana, North Dakota, Oregon, and Wyoming, and a lone county in Maryland. The highest rates of interpersonal violence (>19.1 per 100,00) were found in the southern half of the Mississippi River and in Alabama, in addition to Alaska, Montana, North Dakota, South Dakota, Kansas, Michigan, Maryland, Virginia, and North Carolina.

While the national trends, particularly for drug use disorders, seemingly coincide with what is known from other data reported, Dywer-Lindgren did say that some of the data were unexpected, and most notably pointed to the need for an examination more localized data.

"For drug use disorders, I was surprised at the magnitude of the increases in some counties—we identified several counties where mortality from drug use disorders increased by more than 5000%," she told MD Magazine. "I was also surprised by what we found for suicide: the mortality rate due to suicide declined for the US as a whole between 1980 and 2014, but actually increased in a majority of counties. This is part of why we think it’s so important to look at what’s going on at a local level."

There were at minimum, 4 limitations of the study identified by the authors, including the data being subject to error, the non-validation of the garbage code redistribution algorithms used to redistribute deaths assigned improbable or broad causes due to a lack of available appropriate criterion, difficult-to-quantify uncertainty intervals, and a possible underestimate of geographic variability.

The study, “Trends and Patterns of Geographic Variation in Mortality From Substance Use Disorders and Intentional Injuries Among US Counties, 1980-2014,” was published in JAMA.