The dramatic increase in deaths from illegal opioids — particularly illicitly manufactured fentanyl — is driving this alarming trend. The evidence suggests that the increase isn't because of an increase in the number of people using drugs, but rather by greater lethality of the drugs, primarily fentanyl. Until we more effectively address this component of the epidemic, there will likely be further increases in deaths.
But another momentous negative trend has been lost in the appropriate focus on drug overdose: The decades-long decline in deaths from cardiovascular disease has leveled off. Over a half century, cardiovascular death rates decreased by 60 percent
, with this decrease accounting for about three-fourths of the overall U.S. life expectancy gains in that time. Because increases in drug-related deaths are no longer being offset by decreases in deaths from cardiovascular disease, and because drug overdose tends to kill people at younger ages, the trend toward lowered overall life expectancy has become apparent.
To get the United States back on track to longer lives, we need to make much more and faster progress against both drug overdose and cardiovascular disease.
On the opioid crisis, heightened attention to overprescribing of pain medications, including new prescribing guidelines, has begun to reverse the two-decade-long increase in deaths from opioid prescription drugs. We need to drastically improve management of both pain and addiction. This will require improvements in how medical care, including physical therapy and addiction treatment, is provided and paid for. And law enforcement needs to stanch the inflow of illicit heroin and fentanyl, because lower prices and greater accessibility lead, inevitably, to increased use.
For those addicted to opioids, easy access to medically-assisted treatment, particularly with buprenorphine and methadone, is important. For everyone else, we need to hit the reset button on opioid prescriptions, which, except for terminal palliative care and no more than three days for acute pain, should rarely be used. These are dangerous medications — a few doses and a patient can be addicted for life, and a few too many pills and a person can die; no other class of medication kills such a high proportion of people who take them. Doctors and their state medical boards should be informed each time a person dies from a prescription they wrote.
At the same time, cardiovascular disease remains the leading cause of death in the United States, killing more than 15 times as many people as drug overdoses. We continue to devote insufficient attention and resources to reducing cardiovascular disease.
Initiatives such as Million Hearts, as well as increased access to low- or no-cost screening and treatment, have helped increase the number of people whose blood pressure and cholesterol levels are controlled. But U.S. blood pressure control rates continue to hover at only around 55 percent, even though some health-care systems and countries have achieved rates of about 70 percent.
To get more value for our health-care dollar, we must embrace a non-political approach to greatly improve the quality of clinical care, starting with cardiovascular disease prevention. This means holding every system accountable for delivering care as the best systems do — getting value by rewarding outcomes of blood-pressure control, cholesterol management, appropriate use of aspirin and smoking cessation services.
Some contributors to cardiovascular disease are community-wide; addressing these will require changes outside of the health field. The increase in obesity among people reaching the ages at which heart attacks and strokes are more common is a likely major contributor to the slowing of the decrease in cardiovascular deaths. Exhorting people to eat less and exercise more will fail — only systemic approaches to change the food and physical environments have a chance of success, and these are more likely to work to prevent obesity than attempting to reverse it one person at a time.
Taxing sugar-sweetened beverages is the single most promising intervention to prevent obesity. Excess dietary sodium intake, mostly from salt added to food during manufacture or commercial preparation, is a leading contributor to high blood pressure. Governments in several countries, including Britain, Kuwait and South Africa
, have partnered with the food industry to reduce sodium content and put choice into consumers' hands; a similar approach in the United States would save money and lives.
With sufficient effort, political courage and resources, we can resume increases in life expectancy. When we get the epidemic of opioid overdose deaths under control, as we must, cardiovascular disease will still loom as the leading cause of death in the United States and worldwide. Further substantial increases in U.S. life expectancy depend on our ability to stop the opioid-use epidemic and substantially reduce the burden of cardiovascular disease.