PROVIDENCE – A new study published by Shannon M. Monnat in the Winter 2017 edition of Carsey Research begins with the provocative first sentences: “Americans are killing themselves at an alarming rate. Nationwide, the mortality rate from drug poisoning, alcohol poisoning, and suicide increased by 52 percent between 2000 and 2014.”

Most of this increase, Monnat continued, “was driven by a surge in prescription opioid and heroin overdoses, but overdoses from other drugs, suicides by means other than drugs, and alcohol-induced deaths also increased over this period.”

Especially striking, Monnat found, is that “mortality from drugs, alcohol and suicide increased during a period of declining mortality for other major causes of death, including diabetes, heart disease, most cancers and motor vehicle accidents.”

Further, between 2000 and 2014, Monnat reported: “White males have the highest combined mortality rate for the three causes, but the combined rate for white females increased the most [by 123 percent].”

Who is most at risk?
Young whites, not young blacks or Hispanics, are most at risk, according to Monnat’s analysis, citing statistics from the Centers for Disease Control and Prevention’s Underlying Cause of Death files.

Monnat wrote: “White males made up just 29.5 percent of the young adult population in 2010-2014, but they accounted for a remarkable 57 percent of all drug, alcohol, and suicide deaths in this age group.”

She continued: “Of all the young white males who died in 2010-2014, 48 percent of them died from drugs, alcohol, or suicide; 38 percent of all young white female deaths were due to one of these three causes.”

By comparison, Monnat found deaths attributable to drugs, alcohol and suicide were 13 percent of young black male deaths, 10 percent of young black female deaths, 28 percent of young Hispanic male deaths, and 20 percent of young female deaths.

Rhode Island at the top of the list
Monnat reported that in 12 states, more than half of all deaths among young white adults between 2010 and 2014 were due to drugs, alcohol and suicide, with Rhode Island having the largest share of such deaths at 59.8 percent, followed by Utah at 58.9 percent, Massachusetts at 58.1 percent, New Hampshire at 57.1 percent, and New Jersey at 55.5 percent.

In turn, Rhode Island also had the largest share of such deaths among young white females, at 47.8 percent, followed by Arizona at 47.2 percent, Colorado at 47.1 percent, Nevada at 46.8 percent, and Massachusetts at 46.1 percent.

Looking at the causes
In her conclusion, Monnat said that there was a need to look at the problem and recognize that it was larger than opiates.

She wrote: “The decade-long surge in opiate mortality has rightfully drawn significant media and government attention. Current interventions focus on implementing stricter opioid prescribing regulations, reducing the flow of heroin and fentanyl [a highly toxic and potent synthetic opioid] into the United States, and increasing access to substance abuse treatment and to naloxone – the opiate overdose reversal drug.”

These are laudable first steps, Monnat concluded, but said that the U.S was “not going to ‘Narcan’ its way out” of this problem. There was a need, she continued, to consider “declining social supports and rising income inequality, economic distress and instability that have followed from decades in secure and livable wage jobs for those in the working class.”

Responses to Monnat from the recovery community
Monnat’s analysis and findings were not only provocative, but they appeared to challenge some of the current strategies around recovery and prevention that have been adopted by the Governor’s Overdose Prevention and Intervention Task Force.

ConvergenceRI reached out to Jonathan Goyer, a member of the task force, and to Holly Cekala, the former director of RICARES, a recovery community advocacy group, and now the executive director of Hope for NH Recovery.

Here is what Goyer had to say in response to the Monnat study.

ConvergenceRI: Does the study reveal the need to rethink some of the existing strategies to combat the epidemic in overdose deaths in Rhode Island?
GOYER: I don’t believe it does. Rhode island’s strategy is tailored to meet the need, combined with what is achievable in the short term.

ConvergenceRI: How important is it to address the connection between economic distress, mental health and substance use disorders?
GOYER: It is incredibly relevant to identify the connection between substance use disorders, mental health and economic distress. Unfortunately, Rhode Island has a tendency to silo its funding. And, as long as that’s how the system operates, the burden is on individual organizations to collaborate and coordinate efforts.

ConvergenceRI: Is this a study that you would be willing to share with the Governor’s Task Force?
GOYER: I’m not opposed to it. However, they have their hands full, analyzing Rhode Island Medical Examiner data, and their own barriers to reacting to, or proactively utilizing that data.

ConvergenceRI: Do you have any comments or questions about the study that you would like to share?
GOYER: It’s similar in demographic information to what we are seeing locally, currently.

Here is what Cekala had to say in response to the Monnat study.

ConvergenceRI: Among the findings, the Monnat report found high rates of deaths among young white adults in 2010-2014, where more than half of the deaths were due to drugs, alcohol and suicide. In national rankings, Rhode Island led the list, with New Hampshire not far behind, in 4th place.
CEKALA: I am very saddened by this report although I am not surprised. I have been working [to combat] this epidemic since 2010. We have made great strides in changing how our system works, but apparently it has not been enough.

The [most recent] CDC report puts New Hampshire second in the country on opiate/fentanyl-related deaths, with a 30.9 percent increase from 2014-2015.

I guess, I am just a little overwhelmed still by these findings, even being on the front lines and seeing the devastation, even personally seeing hundreds of thousands obtain and maintain recovery. The numbers continue to rise; there is much work to do.

The sheer numbers of people that needed or still need help with neurological and whole health wellness in New England alone tells us we need critical change in the way we approach these things.

ConvergenceRI: Monnat recommends that there is a need to look at the connection between the declining social supports, income inequality, economic distress and instability and the increase in deaths.
CEKALA: I know economic distress is a factor that is profound in New Hampshire right now, but I am not sure this isn’t true for the whole country.

Folks will say there is a job on every corner, but, in my opinion, for those that have a substance use disorder or a criminal record, they have limited options for work that has benefits or 401k or any paid vacation.

Most jobs available to us are in retail, part-time, with no benefits, at least here in New Hampshire. When I was a child growing up here, most homes had two parents and one was working while one stayed home.

Now that I have returned in 2015, it seems as though many of the family units here have been torn apart or are really unstable. It seems as though there is far less meaningful work for sustaining a family, including health care benefits that are not prohibitive to getting care.

There is a great collateral damage to the families here as well, opiate-addicted babies and many babies being raised by their grandparents. Many of the people that live in the “working poor” circle typically are driven to work several jobs to skate by with the bills and the mortgage; not many can stay home to stabilize a family.

I guess that could, as this researcher suggests, make for a very depressed population due to economic emptiness here in the Granite State.

I see many a family pay with their savings, their retirement, everything they have to get their loved ones care. It is heartbreaking to see.

Some cannot afford the care at all or end up dead waiting for a bed to open. In years past, families were struggling and putting their savings into college education.

When I read this study my heart hurts, I am angry, I want change. I want to shout from the rooftops, you can overcome: I did, my friends did, many in recovery did. But then I am humbled to know that in fact we are the lucky few in a sea of desperation. I am driven to action to help in any way I can to make the lucky few numbers grow to the lucky many.

ConvergenceRI: Is the problem, as Monnat said, larger than opiates?
CEKALA: Most definitely. Nutrition, pollution, loss of spirit, loss of family, less investment in family, working poor families, homes not just housing but homes where family can be made of whatever it needs to be.

I do believe the breakdown of the family as a unit, with two adults investing all they can into their children, not just the four part-time jobs they have to work to put a somewhat nutritious us meal on the table – or rather in the fridge for the kids to heat up while the parent is at work.

Families spend little time each day, dealing with what the day throws at them, together with shared wisdom and support.

Home is where the heart is supposed to be but somehow this study makes me think that heart is broken. Home to many young people is a place you go to after school to turn on the TV, sink into your phone, rummage through the fridge to find some snack in a wrapper and sit down to prepare for fantasy on the Xbox.

Many of us remember the family meal, the homework time, the church on Sunday, the mom or dad getting home from work and those memories seem so much more so precious to me now that I am older and seeing so many in the dark shadows of depression and addiction. What went wrong? According to this study, living is not being embraced, not treasured, not cared for. Maybe a spiritual doctor is needed, I know a health care system change is needed, for sure.

We have long viewed health care as a physical thing, and this has played a huge part in the demise of many of the “numbers,” or rather people, in her study.

I think if we do not start to realize the mind, body and soul need care and nurturing, our world as we know it will continue to stay sick.

ConvergenceRI: Does the study reveal the need to rethink some of the existing strategies to combat the epidemic in overdose deaths?
CEKALA: Yes, I believe it does reveal the need for change in our world, unless we want to throw out the baby with the bathwater.

What has been done for the last 50 years with mental health and addiction is not working for our modern families and communities.

The death toll continues to rise, and our society continues to address it with the same treatment for mental health and addiction.

In recovery, there is a saying: “If we continue doing the same thing over and over, and expecting a different result, that is the definition of insanity.”

Many of us use this phrase to talk about our addiction, and hence the change is the realization that we cannot do the same thing over and over again.

I had high hopes when “health homes” hit the scene but they missed the boat on a few measures: the quality of the home, the benefit of an individual having meaningful work, the benefit of having natural support, and the connection to community in real time, off the Internet, in your life.

Of course, modern science has not yet caught up to addiction services; no one enters treatment and gets a brain scan, then is hospitalized, medicated, nurtured by understanding staff, with blood tests and whole-health physicals. Why not, is my question.

As my friend and fellow advocate Bernadette Gleeson would say: “We have to think about recovery to, instead of recovery from.”

It is hard not to do all you can for someone’s health if you know them personally. I love the Neighborhood Health Station model I was made aware of by Dr. Michael Fine, former head of the R.I. Department of Health, as a place where everyone knows your name and can address your health issues within community.

Brilliant but not popular, I am still not sure why, but I hope we see more of this health care approach before more die alone, disconnected and at rock bottom.

Although many have said and continue to say, “Well you have to hit your bottom before you can change,” I believe this statement to be barbaric and medieval. We as a community can help our neighbors and friends get through the tough times, connect with the family that is struggling. But we have come so far along in the line of thinking, not my people, not my problem.

The world is sick. Toxic water, preservatives, growth hormones, intergenerational trauma, pesticides, fossil fuels, poverty, lower education levels, and economic stress is what we humans are exposed to every day.

Why would anyone be surprised that suicide is on the rise, coping skills have gotten to be less of a skill and more of a thing we all know exists but have trouble harnessing them, [because we] are too embarrassed to practice them, and have trouble finding where we can learn them. It leaves an open door for depression to seep in, and it opens the doorway to drugs and alcohol as the skill we can find on a shelf at the store.

Unless we find a way to implement the change as profound as hand washing before surgery in our medical and “behavioral” health system, we may find it difficult to rise out of counting the numbers of dead.

ConvergenceRI: How important is it to address the connection between economic distress, mental health, and substance use disorders?
CEKALA: You can’t answer this question until you ask yourself: how important are the children left behind by suicide in the family? How important is the mother that buries her adolescent to drug overdose? How important is the veteran that fights and survives a bullet, that then drinks his/ her PTSD away, only to die of liver failure? How important is the American family?

Lastly, how important is the care we need from our providers? I believe it is not just important; it is critical.