Deaths of despair

Abstract

No! It is not time to retire the term ‘deaths of despair’ [1]. The concept is needed more than ever today in countries where drug-related deaths remain at high levels. It draws attention to the need for comprehensive public health and social policies to reverse the damaging upstream conditions, which form the context for these deaths.

It may be that the idea has been misappropriated and is unhelpful in a clinical context. Some in the addiction field seem to have plucked it from its original base in political economy and transported it into discussions about clinical encounters. Such thinking commits the fundamental error of considering a concept as a separate, distinctive phenomenon, divorced from its surrounding theoretical framework.

Addiction psychiatry and psychology focus on the accumulating risk factors which help to explain an individual's overdose, embedding these concepts in an explanatory framework revolving around individual attributes and behaviours. However, the ‘we’ of the addiction field is wider than clinicians. Discussions on the causes of drug-related deaths need to look not only at patterns of drug use, but also at the wider context within which these behaviours develop and become entrenched. The Editorial writers accept this with their brief—rather dismissive—reference to ‘societal despair’, which might be addressed by ‘broad economic improvements’. However, it is precisely with these questions that the concept ‘deaths of despair’ is concerned, looking at issues of regional disparities, left-behind areas, poverty, inequality, deprivation and exclusion.

The influential research by economists Anne Case and Angus Deaton (a Nobel Prize winner) documented the increase in mortality among American men and women without a college degree from suicides, alcoholic liver disease and, most important, drug overdoses. They drew attention to the need to improve the lives of working class Americans, pointing to economic insecurity, widening income inequality and decreasing prosperity over the generations, as well as America's unique failure in healthcare provision [2, 3].

Even after the financial crisis of 2008, in recession and austerity, most European countries did not evidence the slowdowns and reversals in mortality rates found in the United States. The only other wealthy industrialised country at risk of developing in a similar way is the United Kingdom with its long time decline in working class lives [3]. This issue has also recently been thoroughly examined by Walsh and McCartney [4].

While the Editorial quite rightly supports policies and practices like drug treatment programmes, naloxone distribution and safer prescribing practices, these should be set within more general social policies. Case and Deaton recommend inter alia sanctioning the behaviour of the pharmaceutical companies, expansion of Medicaid to cover drug treatment, adoption of NICE-like policies to assess the costs and benefits of treatments, universal healthcare and insurance, improved social safety nets, fairer wage policies and improved education, especially more attention to non-academic (applied and technical) provision.

The term ‘deaths of despair’ was coined to galvanise political thinking. Calls to retire these terms are calls to retire from political involvement, to delegate social problems to the clinician and complacently imagine that large scale changes are neither needed nor possible.

None.