Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

Policy implications of marked reversals of population life expectancy caused by substance use

BMC Medicine201614:42

DOI: 10.1186/s12916-016-0590-x

Received: 4 February 2016

Accepted: 1 March 2016

Published: 10 March 2016

Abstract

Background

Life expectancy has been increasing steadily over the past century in most countries, with only a few exceptions such as during wartimes.

Discussion

Marked reversal of life expectancy has been linked to substance use and related policies. Three such examples are discussed herein, namely the double reversal of life expectancy trends (first to positive, then to negative) associated with reducing alcohol supply in the then Union of Soviet Socialist Republics (USSR), followed by a rapid increase in availability; the impact of the rapid increase of prescription opioids on white non-Hispanics in the US; and the systemic impact of the violence accompanying the drug war in Mexico on the life expectancy of men. Alcohol policies were crucial to initiate the positive reversal in the USSR, and different substance use policies could have avoided the negative impacts on life expectancy of the described large groups or nations.

Summary

Substance use policies can be responsible for abrupt negative changes in life expectancies. An orientation of such policies towards the goals of public health and societal well-being can help avoid such changes.

Keywords

Life expectancy Marked reversals of trend Substance use Policy Public health

Background

Life expectancy has increased steadily over the past century, except during mass pandemics, such as the influenza pandemic of 1918/1919, or during World Wars I and II [13] (see also: http://vizhub.healthdata.org/le/ accessed March 3, 2016). For most countries, the upward trend has remained uninterrupted since the end of World War II. These gradual upward transitions of life expectancy are based on an environment composed of a complex interplay of a variety of major risk and protective factors [4], with the balance improving steadily in the overwhelming majority of countries [13]. Tobacco, alcohol, and illicit drug use are part of these environments; all three categories of substances are among the top 20 risk factors globally, with most of the burden of disease and mortality attributable to tobacco followed by alcohol, with drugs as a distant third [4]. Thus, substance use has been known to have a negative impact on life expectancy and burden of disease, but usually these impacts are counterbalanced by more positive impact factors.

Abrupt changes of directions in life expectancy have been rare, usually triggered by reversal of mortality rates in mid-adulthood, and linked to specific events, such as the aforementioned pandemic or wartimes [3]. However, substance use policies can also create sudden or relatively abrupt population impacts, as will be illustrated herein with three examples.

Examples of marked reversals of life expectancy linked to substance use policies

One, almost classic, example for abrupt reversals in life expectancy relates to the changes associated with the alcohol reforms of the Union of Soviet Socialist Republics in the Gorbachev era, which reversed a negative trend in life expectancy into a positive one following a reduction in the supply of alcohol (increase in life expectancy from 1984 to 1987: men, 3.2 years; women, 1.3 years [5, 6]). When the restrictive alcohol policy was abandoned and alcohol became widely available, the trend in life expectancies reverted once again (decrease in life expectancy between 1987 and 1994: men, 7.3 years; women, 3.3 years [5, 7]). Obviously, these figures represent associations between availability and consumption of alcohol with life expectancy rather than a proof of causality, however, at least for the first reversal, it would be hard to find other explanations, as the increases in life expectancy occurred during a time of economic crisis with no plausible alternative explanations. For the negative trend reversal, attribution of causality is less clear, as this change took place in a period of massive privatization (e.g. [8]) and economic decline, with resulting unemployment (e.g. [9, 10]), community destabilization, subsequent psychological stress (e.g. [11]), and increasing inequality [12]. Some of these variables were included in the most comprehensive econometric modeling on the Russian experience of rapidly decreasing life expectancy [7]. Moreover, alcohol-attributable causes of death were especially impacted in both reversals for life expectancy [5, 7]. Finally, more recent examples of the effects of alcohol policies on mortality confirmed the importance of alcohol policies in the Russian case [13, 14]. In terms of mechanisms, the underlying policy interventions to reduce mortality were mainly alcohol availability restrictions and taxation [5, 13], the latter only for more recent interventions.

The second example concerns drug policy, and specifically policies for regulating prescription opioids (POs) in the United States (US). Overall, larger quantities of POs are used in the US than in any other country (in the latest available statistic for 2011–2013, Canada was a distant second, with about 60 % of the consumption per capita of the US [15]). The rapid increase of PO use and misuse commenced in the mid-1990s, in part by allowing family doctors to prescribe short-acting opioids like oxycodone for relatively common disease categories such as chronic pain [16, 17]. With increased availability of POs, non-medical use increased proportionally along with their associated harm, such as overdose deaths (albeit with some lag) [16, 1820], contributing to a reversal of all-cause mortality of middle-aged white non-Hispanics in the US [21]. While the mortality trend for the general population was steadily decreasing prior to 1999, between 1999 and 2013 mortality increased by 9 % in white non-Hispanics, but continued to decrease in black non-Hispanics and Hispanics. Again, this is an association, but the increase in mortality for white non-Hispanic middle aged Americans was largely accounted for by increasing death rates from drug and alcohol poisoning deaths, suicide, and chronic liver diseases and cirrhosis, all directly or indirectly associated with substance use and substance use policies (drug and alcohol poisoning deaths per definition; suicide [22]; liver cirrhosis [23]; causal links for illicit drugs in general [24]). POs played the major role in this mortality mix, as prescription overdose deaths have become the most prevalent form of overdose death in the past decade in North America, accounting for approximately 40 % of the total drug poisoning deaths [2527]. The rise in heroin overdose deaths in recent years can also be partly attributed to use initiated by way of previous PO use [28].

The third example, also arising from illicit drug policies, relates to the systemic consequences of substance use policies (for a definition see [29]). A recent paper showed that, after six decades of gains in life expectancy for Mexico, the trend stagnated for the period following the year 2000 and, for men after 2005, it actually reversed [30]. This reversal of trends in life expectancy was mainly caused by an unprecedented rise in homicide rates, in large part linked to illicit drugs and the war on drugs, i.e. linked to gang wars and/or conflicts between drug gangs and police or the army [31]. In general, enforcement of prohibitive drug laws has been shown to impact adversely on drug market violence in a systematic review of the evidence [32], and alternative regulatory models will be required if drug supply and drug market violence are to be meaningfully reduced [33].

Conclusions

These examples are chosen to demonstrate that changes in substance use, unlike changes in other risk factors, can affect population life expectancy not only in the long term but also abruptly, reversing decade-long trends. As shown, this is even true for illicit drugs, which have been linked to much less overall mortality and burden of disease than legal substances such as alcohol and tobacco (see above and [4]). The cases cited represent dramatic changes in policies and use patterns, where the connections with overall disease burden are striking. However, there is also ample evidence that appropriate incremental changes in policy or their enforcement have had effects on health outcomes [34, 35].

The health impact in the dramatic cases cited above show that substance use policy decisions can have substantial effects on the burden of disease if policymakers get it wrong; however, they also point to potential substantial benefits if policymakers get it right, i.e. if they establish policies associated with a positive impact on population well-being and the burden of disease, including mortality [33]. Several principles have been identified to allow for such a positive transformation:
  • There should be active monitoring of substance-attributable disease burden and mortality. Identifying rapid changes in substance-attributable causes of death above a certain size will prepare the way for adequate policy changes (see [36], as example for alcohol).

  • Active and integrated substance use policies should be created, oriented at public health gains as a major goal, and with decriminalization of substance use [33, 37] (see also the UNAIDS recommendations for the United Nations General Assembly Special Session on the World Drug Problem [38]). Substance use policies must include legal and illegal substances and psychoactive medications, as evidenced by the second example [35]. The public health approach explicitly includes considerations about harm to others attributable to substance use (i.e. second-hand smoke, effects of substance use on road traffic and operating machinery, violence, effects on the family).

  • Regulation of availability of substances, including regulation of affordability, is one of the cornerstones for substance use policies (see above and [34, 35, 39]).

  • Trade agreements and dispute mechanisms – global, regional, and bilateral – need to be changed so that market restrictions on legally traded psychoactive substances for public health purposes cannot be challenged or nullified [40, 41].

  • Access to treatment and social assistance for heavy users and their families should be improved, which needs to be linked to a reduction of stigmatization. Substance use disorders are the least treated mental conditions, and mental conditions as a whole are less treated than somatic conditions [42]. Improving access to treatment and social assistance would also help in achieving the UN sustainable development goal, specific target 3.5, asking for a strengthening of “prevention and treatment of substance abuse” [43].

  • Policy responses should be relative to the potential of substances to reduce well-being, including, but not limited to, burden of disease and mortality [33, 44].

Declarations

Funding

The research leading to these results or outcomes has received funding from the European Community’s Seventh Framework Programme (FP7/2007–2013), under Grant Agreement n° 266813 – Addictions and Lifestyle in Contemporary Europe – Reframing Addictions Project (ALICE RAP – www.alicerap.eu). Participant organizations in ALICE RAP can be seen at http://www.alicerap.eu/about-alice-rap/partner-institutions.html. The views expressed here reflect only those of the authors and the European Union is not liable for any use that may be made of the information contained therein. The funder had no role in the study design, in the collection, analysis and interpretation of data, or in the writing of the report.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Social and Epidemiological Research (SER) Department, Centre for Addiction and Mental Health (CAMH)
(2)
Campbell Family Mental Health Research Institute, CAMH
(3)
Dalla Lana School of Public Health, University of Toronto
(4)
Department of Psychiatry, University of Toronto
(5)
Institute of Medical Science, University of Toronto
(6)
PAHO/WHO Collaborating Centre, CAMH
(7)
Epidemiological Research Unit, Klinische Psychologie & Psychotherapie, Technische Universität Dresden
(8)
Institute of Health and Society, Newcastle University
(9)
School for Public Health and Primary Care, Maastricht University
(10)
Centre for Criminology and Socio-legal Studies, University of Toronto
(11)
Grup de Recerca en Addiccions Clínic, Institut Clínic de Neurosciències
(12)
Institut d’Investigacions Biomèdiques Agustí Pi i Sunyer, IDIBAPS
(13)
Centre for Alcohol Policy Research, La Trobe University
(14)
Centre for Social Research on Alcohol and Drugs, Stockholm University
(15)
Melbourne School of Population and Global Health, University of Melbourne, Carlton

References

  1. Lancaster HO. Expectations of Life: A Study in the Demography, Statistics, and History of World Mortality. New York: Springer-Verlag; 1990.View ArticleGoogle Scholar
  2. Riley JC. Rising Life Expectancy: A Global History. Cambridge: Cambridge University Press; 2001.View ArticleGoogle Scholar
  3. Deaton A. The Great Escape – health, wealth and the origins of inequality. Princeton: Princeton University Press; 2013.Google Scholar
  4. Forouzanfar MH, Alexander L, Anderson HR, Bachman VF, Biryukov S, Brauer M, et al. Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386:2287–323.View ArticlePubMedGoogle Scholar
  5. Leon DA, Chenet L, Shkolnikov V, Zakharov S, Shapiro J, Rakhmanova G, et al. Huge variation in Russian mortality rates 1984-1994: artefact, alcohol, or what? Lancet. 1997;350:383–8.View ArticlePubMedGoogle Scholar
  6. Shkolnikov VM, Mesle F, Vallin J. Recent trends in life expectancy and causes of death in Russia, 1970-1993. In: Bobadilla JL, Costello CA, Mitchell F, editors. Premature Death in the New Independent States. Washington, DC: National Academy Press; 1997. p. 34–65.Google Scholar
  7. Bhattacharya J, Gathmann C, Miller G. The Gorbachev anti-alcohol campaign and Russia’s mortality crisis. Am Econ J Appl Econ. 2013;5:232–60.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet. 2009;373:399–407.View ArticlePubMedGoogle Scholar
  9. Brainerd E. Economic Reform and Mortality in the Former Soviet Union: A Study of the Suicide Epidemic in the 1990s. Eur Econ Rev. 2001;45:1007–19.View ArticleGoogle Scholar
  10. Cornia GA, Paniccià R. The transition mortality crisis: evidence, interpretation and policy responses. In: Cornia GA, Paniccià R, editors. The Mortality Crisis in Transitional Economies. Oxford: Oxford University Press; 2000.View ArticleGoogle Scholar
  11. Velichkovskiĭ BT. The importance of social stress and effective occupational motivation in the forming of life-style, population health, and the development of demographic processes in Russia. Vestn Ross Akad Med Nauk. 2007;5:41–8 [In Russian].Google Scholar
  12. Lynch JW, Davey Smith G, Kaplan GA, House JS. Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions. BMJ. 2000;320:1200–4.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Neufeld M, Rehm J. Alcohol consumption and mortality in Russia since 2000 – are there any changes following the alcohol policy changes starting in 2006. Alcohol Alcohol. 2013;48:222–30.View ArticlePubMedGoogle Scholar
  14. Grigoriev P, Andreev EM. The huge reduction in adult male mortality in Belarus and Russia: is it attributable to anti-alcohol measures? PLoS One. 2015;10:e138021.View ArticleGoogle Scholar
  15. International Narcotics Control Board. Narcotic Drugs. Estimated World Requirements for 2015. Statistics for 2013. New York: United Nations; 2014. http://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2014/Narcotic_Drugs_Report_2014.pdf. Accessed March 3, 2016.Google Scholar
  16. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug Alcohol Depend. 2006;81:103–7.View ArticlePubMedGoogle Scholar
  17. Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559–74.View ArticlePubMedGoogle Scholar
  18. Imtiaz S, Shield KD, Fischer B, Rehm J. Harms of prescription opioid use in the United States. Subst Abuse Treat Prev Policy. 2014;9:43.View ArticlePubMedPubMed CentralGoogle Scholar
  19. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31:506–11.View ArticlePubMedGoogle Scholar
  20. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618–27.View ArticlePubMedGoogle Scholar
  21. Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A. 2015;112:15078–83.View ArticlePubMedPubMed CentralGoogle Scholar
  22. Ferrari AJ, Norman RE, Freedman G, Baxter AJ, Pirkis JE, Harris MG, et al. The burden attributable to mental and substance use disorders as risk factors for suicide: findings from the Global Burden of Disease Study 2010. PLoS One. 2014;9:e91936.View ArticlePubMedPubMed CentralGoogle Scholar
  23. Rehm J, Taylor B, Mohapatra S, Irving H, Baliunas D, Patra J, et al. Alcohol as a risk factor for liver cirrhosis – a systematic review and meta-analysis. Drug Alcohol Rev. 2010;29:437–45.View ArticlePubMedGoogle Scholar
  24. Degenhardt L, Hall W. Extent of illicit drug use and dependence, and their contribution to the global burden of disease. Lancet. 2012;379:55–70.View ArticlePubMedGoogle Scholar
  25. Xu JQ, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final data for 2013. National vital statistics reports. Hyattsville: National Center for Health Statistics; 2016.Google Scholar
  26. National Center for Health Statistics. NCHS Fact Sheet. June 2015. NCHS Data on Drug Poisoning Deaths. 2015. http://www.cdc.gov/nchs/data/factsheets/factsheet_drug_poisoning.pdf. Accessed March 3, 2016.
  27. National Institute on Drug Abuse. Overdose Death Rates. 2015. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed March 3, 2016.Google Scholar
  28. National Institute on Drug Abuse. America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Presented by Nora D. Volkow. 2014. http://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2015/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed March 3, 2016.Google Scholar
  29. Goldstein PJ. The drugs/violence nexus: a tripartite conceptual framework. J Drug Issues. 1985;15:493–506.View ArticleGoogle Scholar
  30. Aburto JM, Beltrán-Sánchez H, García-Guerrero VM, Canudas-Romo V. Homicides in Mexico reversed life expectancy gains for men and slowed them for women, 2000-10. Health Aff. 2016;35:88–95.View ArticleGoogle Scholar
  31. Gamlin J. Violence and homicide in Mexico: a global health issue. Lancet. 2015;385:605–6.View ArticlePubMedGoogle Scholar
  32. Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: a systematic review. Int J Drug Policy. 2011;22:87–94.View ArticlePubMedGoogle Scholar
  33. Anderson P, Braddick F, Conrod P, Gual A, Hellman M, Matrai S, et al. The New Governance of Addictive Substances and Behaviours. Oxford: Oxford University Press; 2016.Google Scholar
  34. Babor T, Caetano R, Casswell S, Edwards G, Giesbrecht N, Graham K, et al. Alcohol: no ordinary commodity. Research and public policy. 2nd ed. Oxford: Oxford University Press; 2010.View ArticleGoogle Scholar
  35. Babor TF, Caulkins JP, Edwards G, Fischer B, Foxcroft DR, Humphreys K, et al. Drug policy and the public good. Oxford: Oxford University Press; 2010.Google Scholar
  36. Rehm J, Zatonski W, Taylor B, Anderson P. Epidemiology and alcohol policy in Europe. Addiction. 2011;106:11–9.View ArticlePubMedGoogle Scholar
  37. Global Commission on Drug Policy. Taking control: pathways to drug policies that work. Rio de Janeiro: Global Commission on Drug Policy; 2014.Google Scholar
  38. Joint United Nations Program on HIV/AIDS (UNAIDS). A public health and rights approach to drugs. Geneva: UNAIDS; 2015.Google Scholar
  39. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.Google Scholar
  40. Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet. 2013;381:1507–9.View ArticlePubMedGoogle Scholar
  41. Room R, Cisneros Örnberg J. The governance of addictions at the international level. In: Anderson P, Bühringer G, Colom J, editors. Reframing Addictions: Policies, Processes and Pressures. Barcelona: The ALICE RAP project; 2014. p. 46–58.Google Scholar
  42. Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Org. 2004;82:858–66.PubMedPubMed CentralGoogle Scholar
  43. United Nations. Sustainable Development Knowledge Platform. Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://sustainabledevelopment.un.org/sdg3.
  44. Lachenmeier DW, Rehm J. Comparative risk assessment of alcohol, tobacco, cannabis and other illicit drugs using the margin of exposure approach. Sci Rep. 2015;5:8126.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© Rehm et al. 2016