Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
Durkheim and the Sociology of American Overdose Deaths
This item just came up on my news feed:
Drug overdose death rates have increased in 26 states and Washington, D.C., and overdoses continue to outpace car crashes as the leading cause of injury-related deaths, according to a new report.
Nearly 44,000 people die from drug overdoses each year, a figure that more than doubled from 1999 to 2013, and more than half of them stem from prescription pills.
I was surprised by that. I haven’t looked into this deeply at all, but the first question that came to my mind was to how many of these deaths were in fact suicides, rather than overdoses — and indeed, quite where that line would be drawn, given that most adults are well aware that it’s dangerous and potentially life-threatening to take these drugs. It seems to me this kind of death must involve at the very least a carelessness about staying alive, if not a fully-formed and conscious suicidal intent.
I don’t know how such data are collected, precisely, nor what criteria are used to determine whether a drug overdose death was accidental or deliberate. Perhaps someone here would know more and could fill me in. But something about this makes me suspect that what we’ve got on our hands here is a rising suicide rate — of some kind.
I’m persuaded that Durkheim still has a great deal of importance to say to us on the subject of suicide rates. For those of you who haven’t read him, he’s worth it. He was unpersuaded that suicide could be explained entirely by the psychological characteristics or individual circumstances of those who committed it. He instead sought to explore the social facts, or sociology, of suicide rates in different countries at different times. His case — that some societies or cultures within those societies are more prone to suicide — is extremely persuasive.
He drew a distinction among four kinds of suicide: egoistic, anomic, altruistic, and fatalistic. He rejected the idea that altruistic and fatalistic suicides accounted for sufficiently many as to be all that sociologically significant. It’s simplified quite a bit here, but these notes explain what he views as the key concepts:
Egoistic suicide:
-
Individual being insufficiently integrated into the social groups and society
-
E.g. explains difference in suicide rates of Protestants and Roman Catholics (Catholics more strongly integrated)
-
Unmarried and childless less integrated, therefore higher suicide rate
Anomic Suicide
-
Took place when society did not regulate individuals sufficiently
-
Where norms and values are disrupted by rapid social change leading to uncertainty /guidelines for behaviour increasingly unclear
-
Anomic suicide increases during times of economic depression/boom/bust
I have no idea whether anyone is thinking about his work in the context of a “more than doubled” rate of drug overdoses since 1999. But do you find the idea that Durkheim’s thought might be relevant to this as instinctive as I do? Perhaps relevant enough that it might be worth dusting off a copy of Durkheim before assuming that the remedy lies, as this article might suggest, in “education for physicians about ‘overprescribing medication’ and the dangers of prescribing opioids?”
I have to think both physicians and patients already know they’re dangerous, don’t they?
Doesn’t it sound to you as if something a bit deeper is going on?
Published in General
I think most of them are suicides. I really wish I had time to write about the toll of despair. I’m not sure anyone cares.
A terrible indictment on our times.
It would be difficult to sort out the forensics because many of these drugs are depressants anyway, and to the person taking them, it is a statement that emphasizes to himself or herself the hopelessness of his or her own depression.
Added to that is the goofiness of the person on the drug who wants to take more before the existing dose has worn off. It’s easy to lose track of medications when you’ve got your wits about you. When you don’t, it can be impossible.
So no proof will ever exist as to the intention of the overdose victims.
Maybe pills… I remember when a bad batch of heroin came through town and I had at least two clients OD and die. Probably more. You could say that there is only a slight difference between suicide and hard drug use, though.
Well, let’s chalk it up to income inequality, eh?
It happens that a friend of my family nearly died, just a couple days ago, from a presumably accidental overdose of prescription medications. The theory is that she simply forgot that she had already taken her many pills and so mistakenly doubled up.
She was lively and happy when I saw her the day before. But she has remained generally unresponsive since her husband found her practically lifeless on the floor. Her eyes do not respond to light, but her feet respond slightly to touch and her lungs occasionally take an independent breath. For now, that is the extent of her animation.
I’ve known suicidal people and have experienced that impulse plenty of times myself. I believe that my friend was not suicidal and instead overdosed by mistake.
Though I don’t doubt that suicide rates are higher these days for various reasons, errors of medication and adverse chemical reactions are probably also increasing in frequency. Americans are being prescribed medications more often, in combination with more additional medicines, for longer periods of their lives, and while being bombarded by an endless variety of competing chemicals through processed foods.
And hospitalization happens far less frequently and for too-short durations now. First they cut the stays down, explaining it by saying they would make up for it with visiting nurses. Hah! That happened for about a week. Then they cut the home care.
It is tough to manage medications. I’m sure a lot of the deaths are accidental.
And in all fairness to the doctors, one reason these medications are filling up people’s medicine cabinets is because the doctors are trying to help patients who will be in pain when they are by themselves. What to do?
Sadly, the answer won’t be to reinstate longer hospital stays so that medical personnel can help with the pain meds. Noooo. It will be to stop prescribing the pain meds altogether.
Instead of reducing pain meds, the medical profession needs to rethink their self-medication understanding. People need help.
My understanding is that most of these are people who are long-term abusers of opiate/opioid medications. They call this a “death by overdose of prescription medication,” but I think a lot of people read that and assume the dead person was actually the one to whom the drug was prescribed. That isn’t necessarily the case–they could well have stolen them or bought them second-hand. It’s my understanding that long-term abuse of these medications causes physiological changes in the abuser that the individual isn’t aware of. They’ve used the drugs for years, built up a tolerance, and then one day they use what they think is a normal hit and it kills them. The population that this happens to is often guys around forty or fifty–they have decades of opiate use bahind them.
Claire,
Your guess is as good as mine probably better.
Both of these factors have increased since 1999 so they could account for it. On the other hand I have a seat of the pants intuition of another factor. The sophistication level of drugs (endocrine & long slow effects) have increased and the number of different prescription drugs that people are given at the same time has increased dramatically. Personally, I really can’t see how anyone can sort out what is going on unless they’ve gone to medical school and are dealing with it every day. Multiple drugs are fine if someone is in the I.C. with 24 hr watch and we all know that even there mistakes get made. When you are talking about someone in their own home without daily care who is sick and confused to begin with, I really wonder.
If this is what the problem is and not suicide, perhaps daily internet supervision by the physician could help people do better and not make mistakes. By now remote sensing could even check vital signs and if the FDA doesn’t monkey the regs too much it could all be done at very low cost.
Regards,
Jim
Also, though we like to assume that our medical professionals are competent, that’s not always the case. I’ve heard stories of patients being prescribed medications they are known to be allergic to. I’ve known people whose medical records were confused with other patients, and only the patients themselves prevented a medical emergency due to clerical mismanagement.
With increasing bureaucracy, senseless regulations, and a greater workload faced by fewer physicians, those errors are probably becoming more common.
The VA is experimenting with computer home care. It’s pretty cool. It would help a lot.
Higher potency drugs advance addiction rates and accelerate the pace of users hitting their predictable end points–sobriety or death. It is unlikely that the current trend of increasing drug deaths by suicide/user negligence will persist for Darwinian reasons.
Most likely the archetypal suicide will still be a gun-using single, protestant, white male living alone in a red state.
Durkheim nor anyone else has ever had a way to directly measure the spiritual health of a society, to ascertain whether there was a widely shared, forward-looking excitement about the future or a growing despair that the best is best and all is winding down. Obviously, individual lives have their own trajectories but there must also be something to the larger shared currents of life.
I wonder whether there is some pernicious psychological effect from the bitter irony of “Hope and Change” being the slogan of a political movement that openly hates American success, leadership and pride and seeks to undo all the best in our nation out of sheer spite and ideological perversity. I could empathize with one who might think that if Obama is the best to hope for and the American Omega point, then maybe it is time to check out.
Just curious. The report says half of overdoses are from prescription drugs. But is this a language problem? Claire seems to be assuming that the person who overdosed did so on their own prescription medication. Is that really so? If someone ODs on Oxycodone they bought on the street, is that classified as an OD on illegal drugs or as an OD on a prescription medication?
A lot of the ads on television for drugs note if one experiences a desire for suicide, one should stop taking the drug and call one’s physician.
Anecdotal for you perhaps, but not for me.
A man I had met and enjoyed talking with went into the hospital and had the surgery. He was prescribed a medication. The medication made him deeply depressed. He had stopped taking the medicine but was not improving in his mental outlook. He was home with his family but could scarcely find the energy to get out of bed and face the day.
He was scheduled to go back to his doctor on Thursday and be examined. He killed himself on Wednesday. His wife took the children out to a necessary function. He found tools, broke open his gun cabinet (because his wife had hid the keys), and put one of those guns to use on himself.
A woman is minus her husband. Two children are minus their father. A congregation is without a deacon. A company is without a very good representative who enjoyed his job.
What is it about the new drugs that require all of us to be warned about possible adverse consequences? Who wants to become psychotic? What doctor isn’t considering this issue? One wonders if an older class of drug might be less humanly toxic to the recovering patient?
I don’t know if a significant number of those people are suicides. I do know we have a HUGE problem with prescription drug abuse in the US, especially narcotics.
The US is 5% of the worlds population and consumes about 85% of all prescription narcotics. Between 1999 and 2010 use of prescription narcotics quadrupled. The pressure on physicians to prescribe narcotics is huge.
Part of this began in the late 1980’s when several studies suggested we were underprescribing for pain, and overestimating the risk of addiction. As a result by 2001, the Joint Commission ( which accredites medical facilities) included pain as the “fifth vital sign”. So in the ER every patient has to be asked what his level of pain is, usually on a scale from 1 to 10. Failure to adequately address this pain can result in sanctions. In addition a series of new medications became available which concentrated a large amount of narcotics in each pill for extended release. These were very successfully marketed to the public and demand for them was soon huge.
Another factor is the “consumer” model of health care that now predominates. Licenses, jobs and pay are tied to “patient satisfaction surveys” and patient complaints. Score poorly, or accumulate compaints and your ability to earn a living can be threatened.
Finally we live in a country that demands immediate gratification, that nobody ever be uncomfortable, ever, and that there’s a pill for every problem.
Combine all these factors and you have the problem we have now. I can not tell you the number if drug seeking patients we see every day in the ER. Most patients insist their pain is a “10”. Playing on their smart phone, joking, normal vitals, not sweaty.I see patients over and over for example for toothache. The ER tratment ( I’m no dentist) is an antibiotic and a pain reliever maybe an attempt to block the tooth with a nerve block. Most dentists, now wise to this only prescribe NSAIDS. I get patients demanding narcotics and refusing any attempt to inject the pain locally. So, I write the script, and soon get a call from the pharmacy that ” the patient only wants the Vicodin”. I’ve been yelled at by parents for not prescribing Percocet for their 12 year olds ankle sprain. Threatened with lawsuits for not giving Dilaudid. Referred to the State Medical Board for not prescribing pain meds ( 3 patients in one day, a husband and wife and a friend. Tossed out, the ONLY time in 30 years I’ve been reviewed like that).
The tide is turning a little. The physcian who started the whole thing has recently admitted he might have been wrong. We now have state databases to track Narcotic RX’s. Pill mills have been shut down and “Candyman” doctors removed from practice.
Who is Responsible for the Pain Pill Epidemic
Prescription for Addiction
Explaining the rise in legal narcotic misuse and addiction
There’s no question in my mind that a significant cause of suicides are these new medications concocted to alleviate depression. My own experience with one of those popular drugs 15 years ago was. First relief. Second Nothing . Third a feeling that something was wrong with me and I needed a ‘drug’ to be normal. Fourth a decision to stop taking that drug. Fifth depression – I had never felt before. 3X whatever depressed I felt before the prescription feelings of hopelessness and emptyness. Suicidal thoughts AFTER I stopped taking it, not before.
I’m okay now. Self-medicating with Guinness.
I know I should wait for an actuary or a physician (i.e., someone who might know something about it) to weigh in on the reliability (and variability) of cause of death reporting, but ascribing overdoses only to carelessness might be misguided. Opiates require an increasing dosage to mitigate pain. Eventually the dosage required kills you. That’s the choice in a lot of terminal cases: pain or death. Overdose could be the reported immediate cause of death. The study could be sloppy. It’s happened. (And the last time this drum-beat started up, people in severe pain were getting put on alcohol drips, for God’s sake.)
Yes, there’s evidence for this.
Claire, how do you not know about Becker and Posner’s paper on this very subject? ;-)
Actually, I owe Troy an OP on this paper, now that I’ve secured Posner’s permission to discuss it on this site. Plenty of yummy nuggets in there, including the concept of suicide as an option exercised when a certain strike price (degree of unhappiness – including dashed hopes) is reached.
And yes, many are culturally averse to having “too much of a hand” in their own death, and so seek out less surefire means, such as risky behavior, or basic neglect of the body, as a way of courting death. I call this the “You can keep me from self-murder, but you can’t make me live!” attitude.
No idea: as I said, I haven’t looked closely at this, but would find it interesting to try.
Indeed it is. How did I not know, indeed?
We are living longer than ever. Medicine now allows us to save people that would never be saved before. I have friends that would be dead now if it was not for modern medicine. One side effect of this is that some of those people that are now alive but would have been dead aquired a chronic pain condition in the saving. There are some that say don’t give out pain meds because they cause issues. But if the meds allow a person with chronic pain conditions to live a more normal (normal is out of the question) life then should doctors not help them as much as they can? But even with the pain meds a chronic pain person still has pain. Day after day of pain in one form or another, after years of that one might consider taking their life just to end the suffering. Or maybe the different guy is suffering long term pain, just takes one too many pills to try to get that moment of blessed relief where they do not hurt.
You want to stop the pain overdose situation? Easy. Go back to the old days where we did not save people and let them die. That way they will not have to live with the pain and maybe off themselves trying for relief. That would make the statistic better and all those people not in their situation much more comfortable with stupid statistic comparisons.
For non-prescription drugs, and even some mood-altering prescription drugs, you have to ask why the drugs are needed, or perceived to be needed. I read an article the other day arguing something of a duh point, that people who are busy and happy aren’t tempted to do drugs. Obviously. What makes some people satisfied and some not? Personality has a lot to do with this, but circumstances can certainly affect it too.
I personally think Durkheim’s anomie argument has some efficacy in the modern world. As Viktor Frankl observed in concentration camps, people who had a reason to live and some meaning in their lives were a lot more likely to survive. Humans have a will to meaning, but it’s easy for life to be rather meaningless in our atomistic modern world. We need community and something to believe in, but beyond that, the smacking down of traditional family values and sexual mores is very confusing and I think depressing. Hook-up culture really really leads to depression, especially for women from what I’ve read.
People also need a blueprint for their lives. Everybody doesn’t have to live the same life, but we need some idea about how meaningful lives might be lived. If there is too much choice and not enough blueprint, individual anomie is common, if not likely. And that can be depressing.
There are drugs now that may increase the likelihood of suicide. During my divorce I was prescribed anti-depressants. Besides a little weed back in college, I don’t like drugs. Within 5 days of taking this stuff I had thoughts of running my car over the canyon. My guess is that there are many folks who experienced and possibly acted out based on similar drugs.
On the other hand, maybe not, if you value avoiding hospital-acquired infections.
I can’t say I know where the ideal balance is, but there are good reasons for avoiding prolonged hospital stays if you can.
Did they adequately sort out the confounding here?: people who are functional and aren’t in pain are also more likely to be busy and happy, too – it’s just easier for them to be.
It is very frustrating to have mobility and cognition impaired by poor health, and – something of a duh point – harder to be productive when you are experiencing this sort of frustration.
Yep.
Yep. If you value your wits, medicating to painlessness really isn’t an option. A smart person medicates to the point where it’s bearable enough to get by.
Exactly. Do not suffer an unnatural to live.
Have to wonder if this apparent increase in overdose deaths might not be the result of different record keeping practice, as is the case with a recent uptick in reported deaths among women giving birth.
Apropos of nothing: Over 2.5 million people die in the United States each year.
This is a tough one, in part because many patients don’t know the difference between a drug allergy and an intolerance, and also because often the question, “Are you allergic to any drugs?” is meant to cover intolerance, too, but a patient who does know the difference may not be aware of that.
If a few times in your life, antibiotics whose names you don’t remember gave you beautiful red giraffe spots, but other than that you were fine, what are you supposed to say? Why should the doctor care about a mere cosmetic change, especially when you can’t remember which drug caused it?
Well, one thing that can be – and is being – done is to mix a narcotic medicine with a famously hepatotoxic non-narcotic drug like paracetamol (acetaminophen). This raises the stakes of getting high: do you want it so bad you’ll give your liver for it?
And some of us are lucky enough to break out into hives when we’re given an excess of opioid medication. Perhaps something could be added to opioids to give most people this response: uncontrollable, skin-shredding itching does tend to harsh one’s mellow.
Much is conflated in this discussion. The vast majority of the deaths in question are those suffering from addiction(a dependency) as their primary illness – not chronic pain or secondary to other conditions. I speak from my own experience after 24 years of recovery from opioid dependency. Anyone in 12-step recovery will tell you there are three alternatives to complete abstinence: jails, institutions and death. Before recovery, every addict believes him/herself to be the exception. “Not me.” “I can control it.” This is denial, the number one symptom of addiction. They will also tell you that the solution to addiction is “spiritual.” For some, that means finding a conscious contact with God. For others, this simply means finding fellowship – warm relationships with other human beings, where one may simply feel useful and accepted. Now difficult here!
Addicted individuals often describe having a “God-shaped” hole which they attempted to fill with mood altering drugs, especially opioids, which offer a feeling likened to satiety or comfort. Addicts frequently describe being “uncomfortable in my own skin.”
In this society it is difficult to know one’s inner self. In large part, this is because experience of self depends in large measure upon honest interaction/feedback we receive from others who are emotionally healthy. This, I believe, is the fundamental human dependency for which drugs are a poor substitute. Instead, our atomized culture demands quick fixes, like drugs with narrow therapeutic windows. Dependency society plus dependency psychology = drug dependency +OD epidemic.
That sounds quite plausible. But a (true) belief that they’re using the controlled substance they’ve been prescribed in a responsible, well-controlled manner is also presumably a “symptom” of people using prescribed controlled substances in a responsible manner, no?
So what you’re saying seems to be that we that we human beings as individuals have no way of telling responsible, well-controlled use apart from addicted use? Only those outside ourselves can tell?
Opioids are great for acute pain, for a limited period of time. Use for chronic pain is problematic. There is probably a small cohort whose chronic pain cannot be controlled other than with opioids. Given inevitable “mission creep” of all endeavors – including medical – demanding some limiting principle, use of opioids for chronic pain has exploded and this is the source of much of the overdose problem. The individual prescribed the meds may be taking them or selling them. Recovering addicts often joke, “How can you tell when an addict is lying?” Answer, “When his lips are moving and even then, he may be a ventriloquist.” The creativity expressed by “patients” in obtaining opioids is astonishing.
To answer your question, I would say an individual taking opioids chronically may be incapable of sufficient self-honesty to know whether or not he is addicted (denial, rationalization, minimization, justifications at work). Addiction is defined as continued use in the face of adverse consequences (including symptoms of physical withdrawal). Families and friends often become part of a denial system and may be of limited help. Counselors who treat addiction are quite good at sorting out the question of whether or not an individual is an addict.
OK, let’s talk some numbers. If an arthritic woman who’s had multiple surgeries uses 4 or fewer half-tabs of Norco 5/325 a week to take the edge off the worst chronic pain, how likely is that to be an addiction?
So, if as happened to me, stopping Benadryl cold-turkey causes vomiting, sweating, fever, and hives, does that make someone a Benadryl addict?
I’m now much more careful about ensuring that Benadryl doesn’t become my primary antihistamine, but the idea that I was “addicted” to this substance simply because it was the biggest hammer I could easily get my hands on to manage allergy and asthma symptoms seems rather nuts.
(I’ve had multiple surgeries and injuries, incidentally. No opioid I was given for those has been as hard to wean myself from as Benadryl – or Prednisone.)