‘Swallowed by Opioids’? A New Look at Appalachian ‘Deaths of Despair’

‘Swallowed by Opioids’? A New Look at Appalachian ‘Deaths of Despair’
Hermens/Lexington Herald-Leader via AP)
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Ever since Anne Case and Angus Deaton of Princeton University coined the term “deaths of despair” in their 2015 study on rising mortality rates among working class whites, the public and policymakers have been focused on the role of long-term un- and under-employment in rising levels of suicide, addiction and alcoholism among white, less-educated workers. The jobs that had sustained the white working class, it was argued, moved out and drugs and alcohol moved in. The Case-Deaton study codified an unease in the public mind that automation and international trade had deprived working class whites of jobs they had depended on for generations to achieve and maintain middle-class lives. Productive work was replaced by social collapse culminating in rising numbers of early deaths.


Gilbert Metcalf of Tufts University and Qitong Wang at the University of Southern California have taken a different cut at the data and arrived at an alternative theory: In some of the hardest-hit regions of the Appalachian coal-belt, declining employment may not have been the principle source of opioid-related mortality. The “origin story” of addiction and death, they say, was not the absence of work but the coal jobs themselves.


The Metcalf and Wang thesis focuses on the injuries and health risks associated underground coal extraction in Appalachia. Cramped underground working conditions lend themselves to work hazards and injuries that, in many cases, require treatment with opioid pain-killers. With the Appalachian coal workforce declining 46 percent between 2011 and 2016, the remaining workforce, the authors argue, may have been under pressure to keep working even when injured for fear of being replaced by those who had already been sidelined. To hold onto their jobs, injured workers relied on opioid pain-killers. The more commonplace the use of opioids, the greater the community-level exposure — legal and illegal — resulting in higher rates of addiction and death across the community.


The most striking finding of the paper is that a decline in coal employment was associated with lower rates of opioid deaths. Across counties, as the rate of coal employment rises, so does opioid-related mortality. For men in the most mining-dependent Appalachian counties, opioid mortality rates were one-third higher than in those with lower levels of mining employment. Further reinforcing the link between mining employment and community-level opioid exposure, Metcalf and Wang find that opioid deaths among women in these mining-dependent counties were 80 percent higher than in other, less mining-dependent counties — even though few women work in the coal mines. The study estimates that if Appalachian coal mining had remained at its 2011 peak, opioid death rates would have been 15 percent higher than they were in 2016 due to the ongoing injury-pain-community exposure opioid cycle. To be sure, Metcalf and Wang do not fully discount the despair theory. Chronic unemployment destroys, and improving our policies and programs meant to address this challenge should be a top national priority.


At the same time, the Metcalf and Wang study makes an important point about not mourning the loss of these jobs too much. Both entertainment and politics tend to romanticize work in the mining industry (“A Coal Miner’s Daughter” and the “Trump Digs Coal” signs of the 2016 election) with images of coal-blackened faces coming to the surface after a day of extracting riches from the Earth. The reality is much crueler. Physically taxing jobs often put workers at risk of injury, disease, and, it turns out, addiction and death while laying the foundation for community-wide opioid epidemics. Something to consider as we try to “bring back coal.”


Brent Orrell is a resident fellow at the American Enterprise Institute.

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