Pallbearers unload a casket at Smith Cemetery in Strunk, Ky., earlier this year. McCreary County has about 18,000 residents and limited economic opportunities. (Bonnie Jo Mount/The Washington Post)

Over the past year, The Washington Post has explored a historic increase in premature death among white Americans, particularly middle-aged women living in small towns and rural areas. Here are the key findings from The Post’s “Unnatural Causes” series:

1. The nation’s health is deteriorating, with no end in sight. Since the turn of the century, white women have been dying prematurely in a slow-motion crisis driven by decaying health in rural and small-town America, a Washington Post analysis found. While rates of early mortality have continued to fall for women of other races, and have flattened out among white women in big cities, death rates among small-city and rural white women in their early 40s, for example, have shot up 47 percent since 1990.

Heavy drinking, suicide and drug overdoses — primarily from opioids — are driving the phenomenon. And though rates of premature death are rising fastest among white women, the effects of ill health are widespread: In 2015, overall life expectancy in the United States dropped for the first time in more than two decades.

Read more about premature mortality.

Explore the data.

Examine the statistics in your county.


2. Prescription drugs play a powerful role in the crisis. And it’s not just opioids. A third of white women who have died of opioid overdose since 1999 also had anti-anxiety drugs known as benzodiazepines in their bloodstreams — a potentially deadly combination, The Post found. Read more about opioids and benzos.

White women who take opioids are particularly likely to be prescribed additional drugs to manage the symptoms of long-term opioid use, The Post found. In addition to anti-anxiety medication, they might get drugs to help them sleep or to ease a condition known as “opioid-induced constipation.” A Post analysis found that nearly 6 in 10 working-age women who take opioids have three or more additional prescriptions. Read more about follow-on prescriptions.

Meanwhile, The Post found that the suicide rate has risen alongside prescriptions for anti-depressants and other psychiatric drugs, which are often ineffective. “Multiple drugs overload the system in ways we can’t predict,” said Rene Muller, a psychologist at Johns Hopkins. Read more about suicide.


Some of the pills that Karen Franklin regularly takes during an eight hour period. Franklin suffers from a back injury and lives with chronic pain. She said that despite taking morphine and other prescription medications her pain level is usually a "10". (Bonnie Jo Mount/Washington Post)

3. Doctors could be doing more to prevent opioid addiction. A third of Americans who have taken prescription opioids for at least two months say they became hooked on the powerful painkillers, according to a Washington Post-Kaiser Family Foundation survey. But more than 6 in 10 said doctors offered no advice on how or when to stop taking the drugs. And 1 in 5 said doctors provided insufficient information about the risk of side effects, including addiction. Read the poll results.


4. The federal government could be doing more, too. The Drug Enforcement Administration initially tried to combat the opioid epidemic by targeting wholesale distributors accused of leaking hundreds of millions of pills a year into the hands of illicit dealers. But in 2012, the drug industry fought back. The DEA virtually abandoned its campaign, shifting to other forms of enforcement. And this year, Congress passed and President Obama signed a measure to take away the DEA’s most potent weapon: The authority to immediately shut down suspicious distribution centers.

Read more about the DEA pullback.

Read more about the cases against drug distributors.

Meanwhile, the drug companies have hired some of the best and brightest DEA regulators. At least 42 DEA personnel — 31 of them directly from the division that regulates the pharmaceutical industry — have taken jobs in the pharmaceutical industry since the campaign against distributors began.

Read more about the revolving door.


5. But heavy drinking is also a major factor. The rate of alcohol-related­ deaths for white women age 35 to 54 has more than doubled since 1999, The Post found, accounting for 8 percent of all deaths in this age group. Liver failure has risen alongside dangerous drinking among white women, who report a 40 percent increase in binge drinking since 1997.

Unlike suicides and drug overdoses, alcohol-related liver failure is increasingly striking white women in big cities as well as in rural areas, The Post found. Read more about the trend and the role of alcohol marketing.


6. The epidemic of substance abuse is damaging entire communities while destroying individual lives.

In Tecumseh, Okla., where Anna Marrie Jones died at age 54 of cirrhosis, family members buried her alongside friends and relatives who had died in the past decade at ages 46, 52 and 37. Jones had buried her fiance at 55. She had eulogized her best friend, dead at 50 from alcohol-induced cirrhosis. Read more about Jones.

In Jasper, Ala., opioid painkillers are so enmeshed in the local economy that they’re traded for lawn mowers and school clothes. Read more about Jasper.

In McCreary County, Ky., there has been a 75 percent increase in the mortality rate for white women age 35 to 59, one of the highest increases in the nation, The Post found. Separate research at the University of Washington found that McCreary County women are more likely to be obese and to engage in life-shortening behaviors such as binge drinking than in previous generations. Read more about McCreary County.

In Farmington Hills, Mich., in the 11th year of her opioid addiction, Amanda Wendler decided to pursue one of the newest treatments for heroin: A monthly shot of a drug called naltrexone, which blocks the effects of opiates on the brain and makes getting high impossible — but also comes with dangerous side effects. Read more about Wendler.

In Chillicothe, Ohio, and surrounding Ross County, 40 people died of overdoses last year, almost all of them opioid related. That number has tripled in the past three years. “It’s the Zombie Apocalypse,” said the local coroner. Read more about Chillicothe.

And in South Charleston, W. Va., officials are starting to focus more resources on “opiate orphans,” who have lost their parents to drugs. Three of the most recent ones live in a small house in South Charleston: Zoie, 10, who believed that her parents had died in their sleep; Arianna, 13, who was just starting to wear her mother’s old makeup; and Zaine, 17, who had been the one to discover his parents dead of a heroin overdose that morning in 2015, and whose grades had been dropping ever since. Read more about Zaine.


In South Charleston, VW. Va. Madie Clark, right, with Zaine and friend Jewels Hudson, moved in with her grandchildren after her daughter, their mom, died of an overdose. Clark is a former addict. (Bonnie Jo Mount/Washington Post)