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Policy implications of marked reversals of population life expectancy caused by substance use
BMC Medicine volume 14, Article number: 42 (2016)
Life expectancy has been increasing steadily over the past century in most countries, with only a few exceptions such as during wartimes.
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.
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.
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 [1–3] (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 , with the balance improving steadily in the overwhelming majority of countries [1–3]. 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 . 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 . 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. ) and economic decline, with resulting unemployment (e.g. [9, 10]), community destabilization, subsequent psychological stress (e.g. ), and increasing inequality . Some of these variables were included in the most comprehensive econometric modeling on the Russian experience of rapidly decreasing life expectancy . 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 ). 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, 18–20], contributing to a reversal of all-cause mortality of middle-aged white non-Hispanics in the US . 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 ; liver cirrhosis ; causal links for illicit drugs in general ). 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 [25–27]. The rise in heroin overdose deaths in recent years can also be partly attributed to use initiated by way of previous PO use .
The third example, also arising from illicit drug policies, relates to the systemic consequences of substance use policies (for a definition see ). 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 . 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 . In general, enforcement of prohibitive drug laws has been shown to impact adversely on drug market violence in a systematic review of the evidence , and alternative regulatory models will be required if drug supply and drug market violence are to be meaningfully reduced .
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 ). 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 . 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 , 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 ). Substance use policies must include legal and illegal substances and psychoactive medications, as evidenced by the second example . 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).
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 . 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” .
Lancaster HO. Expectations of Life: A Study in the Demography, Statistics, and History of World Mortality. New York: Springer-Verlag; 1990.
Riley JC. Rising Life Expectancy: A Global History. Cambridge: Cambridge University Press; 2001.
Deaton A. The Great Escape – health, wealth and the origins of inequality. Princeton: Princeton University Press; 2013.
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.
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.
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.
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.
Stuckler D, King L, McKee M. Mass privatisation and the post-communist mortality crisis: a cross-national analysis. Lancet. 2009;373:399–407.
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.
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.
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].
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.
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.
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.
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.
Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug Alcohol Depend. 2006;81:103–7.
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.
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.
Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31:506–11.
Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618–27.
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.
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.
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.
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.
Xu JQ, Murphy SL, Kochanek KD, Bastian BA. Deaths: Final data for 2013. National vital statistics reports. Hyattsville: National Center for Health Statistics; 2016.
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.
National Institute on Drug Abuse. Overdose Death Rates. 2015. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed March 3, 2016.
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.
Goldstein PJ. The drugs/violence nexus: a tripartite conceptual framework. J Drug Issues. 1985;15:493–506.
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.
Gamlin J. Violence and homicide in Mexico: a global health issue. Lancet. 2015;385:605–6.
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.
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.
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.
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.
Rehm J, Zatonski W, Taylor B, Anderson P. Epidemiology and alcohol policy in Europe. Addiction. 2011;106:11–9.
Global Commission on Drug Policy. Taking control: pathways to drug policies that work. Rio de Janeiro: Global Commission on Drug Policy; 2014.
Joint United Nations Program on HIV/AIDS (UNAIDS). A public health and rights approach to drugs. Geneva: UNAIDS; 2015.
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.
Gleeson D, Friel S. Emerging threats to public health from regional trade agreements. Lancet. 2013;381:1507–9.
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.
Kohn R, Saxena S, Levav I, Saraceno B. The treatment gap in mental health care. Bull World Health Org. 2004;82:858–66.
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.
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.
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.
Antoni Gual has received honoraria and travel grants from Lundbeck, Janssen, D&A Pharma, and Servier, all outside and unrelated to the work for this project. Jürgen Rehm has received educational grants, honoraria, and travel support from Lundbeck, all outside and unrelated to the work for this project. The other authors do not have any potential conflicts of interest to declare.
JR conceptualized the article and wrote a first draft of the original submission and of the revised manuscript. All other authors helped to finalize the text and approved of the final version. All authors read and approved the final manuscript.