Drug Poisoning Update for 2021 Data

I haven't done one of these in almost three years, but I wanted to do an update. Here is my most recent one with data through 2018, also with links to prior years' analyses. I think not much has changed about the overall narrative, so I'll direct readers to the previous years' posts for those details.

The CDC's large mortality file gets posted here, in case anyone wants to download and do their own data mining. 

There were 107,027 drug-related deaths in 2021. This includes 98,722 accidents, 4,239 suicides, 3,852 incidents of "undetermined intent", and 214 murders. (Not included in the 107,027 figure is 7,017 "other" deaths, where drugs were mentioned on the death certificate but weren't listed as the immediate cause of death. Some of these really are caused by drug use, so presumably they should count for anyone who's concerned about drug-related public health issues.) In the past I've made a big deal about the difference between the total and accidental deaths. Sensationalist journalists reach for the largest number they can find, so they cite the total. This will often be in the context of an "opioid epidemic" story. But it doesn't make much sense to blame suicides on the opioid epidemic. A suicide is a death that would most likely have happened anyway, just by another means. At any rate, as the years go on the "accident" category is becoming such an overwhelming majority that it feels a little pedantic to make this distinction. Still, bonus points for honesty to any journalists who cite the 98k figure rather than the 107k figure. Here's a chart of the proportion of deaths by the various categories over time, where you can see "accidental" swallowing up a greater and greater share of the total:

I do suspect a lot of these "accidental" overdose deaths have a question mark over them. A lot of these people are taking such tremendous risks (like shooting up alone with a powder of unknown origin and potency) that it's worth asking whether it should count as an attempted suicide. But the best I can do is analyze the data we have and caveat with my personal suspicions. 

Above is a chart showing the deaths by major substance categories. The pink line that dominates in the most recent years is "synthetic narcotics", which mostly refers to fentanyl being sold as a street drug. Fentanyl has largely replaced heroin as the major opioid of abuse. This view can be slightly misleading in the following sense: most drug poisonings are multi-drug interactions. So if one category of drugs is skyrocketing, it can drive up the apparent deadliness of other drugs (even if the risk or abuse rates of, say, cocaine or benzodiazepines are basically unchanged). This is actually my value-added. Because this CDC file is at the individual record level, I can count, say, cocaine deaths excluding fentanyl and heroin. I think what looks like a general trend of increasing drug deadliness is in reality almost entirely a fentanyl story. 

Below I have created a similar time series, but this time I'm splitting each substance into two lines. The first line is unconditional count, and it should match the chart above. The second (necessarily lower) line excludes deaths involving heroin or fentanyl. The normal green line is cocaine deaths, while the pukish-green line is cocaine deaths excluding those that also involved heroin or fentanyl. The first looks like it's taking off, the second looks like it's relatively flat. This is clearly a case of fentanyl driving up cocaine-related deaths. Presumably in most of these deaths, the cocaine was either not a factor or not sufficient to kill without the added effect of a potent opioid. 

For clarity (the above chart is too busy to read clearly), here are prescription opioids inclusive and exclusive of heroin/fentanyl. The dishonest way to report on this is to look at the raw number and say "prescription opioid deaths are still rising." A more honest assessment is that prescription opioid deaths are falling, but the extremely high mortality of illicit fentanyl users is spuriously driving up the number of death certificates that mention prescription opioids. There are fentanyl users who happen to have prescription pills on them when they fatally overdose, and there are people who abstain from fentanyl but who fatally overdose on prescription pills. The non-overlap in these categories explains the huge gap between the two lines.

Here's benzodiazepines. Almost all benzodiazepine-related deaths involve some other substance, typically an opioid but sometimes alcohol or some other prescription medication. This is once again a story of fentanyl driving up the total.

Here are "psychostimulants with abuse potential", which mostly means methamphetamine. I think I have heard some commentators suggest that meth is on the rise again, which possibly exonerates opioids. The rising rates of meth use, this narrative goes, are simply a continuation of a longstanding trend of increasing overdose rates, which extends back to the 1970s (possibly earlier). Meth just happens to be in vogue again. This appears not to be the case. Undoubtedly the red line is increasing dramatically, but in the most recent year the blue line is almost three times as high as the red line. Pure meth-related mortality is several times higher than it was twenty years ago, but at the same time the vast majority of meth-related drug poisonings also involved fentanyl or heroin. 

By the way, heroin deaths seem to have reached a peak in 2017, at 14,870. By 2021 they were down to 9,064. So overwhelmingly the most fatal street drug is fentanyl, which appears to have almost totally taken over the heroin market. 

If you want more information about which drugs in combination are killing people, here is a cross table. (To read the lower table, take the second column of the first row. Read this as "22.48% of heroin deaths also involved cocaine.") 

The elephant in the room here is that I've added the Covid years to the analysis. My previous update went through 2018, where drug-related deaths appeared to be leveling off. Well, 2019 looks like a clone of 2017, if not slightly worse. 2020 and 2021 both saw large increases over the prior year. I don't know if the "deaths of despair" narrative makes sense here, or if we're just seeing a continuation of that longstanding trend reaching back to the 1970s. Shouldn't despair have been worse in 2020, when lockdowns were harsher, society was more closed, and drug users would have been more likely to shoot up alone (thus not having anyone who could call for help if they overdosed)? Or was there some kind of accumulation of despair from 2020 to 2021? That is, even though 2021 was milder in terms of social isolation, that isolation was still wearing people down and driving them to risky drug use. 

I have limited patience for the notion that drug-related mortality can exponentially increase for multiple decades. Obviously this can't go on forever. I haven't done a population dynamics calculations to check this, but at some point you'd start running out of drug users. A little Googling suggests there are around a million heroin users in the United States. (Maybe double or triple that if you think most heroin users are homeless and out of reach of household surveys of drug use). If these are the people being killed by fentanyl, then with the numbers we're seeing it would only take a few years for them to all die off. Even with new addicts refreshing their ranks, the mortality is high enough that some depletion should be happening. And these very high mortality rates should be scaring off a lot of potential new users. (Presumably that's happening, but some countervailing force is attracting them?) We should probably take seriously the notion that a large number of deaths are misclassified. Does anyone have a story for why methamphetamine-related deaths, excluding those involving heroin/fentanyl, have increased 30-fold since 1999? Were we perhaps undercounting back then and/or are we overcounting now? I don't want to selectively dismiss or down-weight government data, but at the same time this kind of dramatic increase makes me really suspicious. My attempt to find some pattern in all-cause mortality or a redistribution from one cause-of-death category to another was pretty inconclusive, but that's not to say a deeper dive wouldn't turn up something interesting. 

How to Means Test Social Security and Medicare

Social Security and Medicare make little sense as anti-poverty programs. They pay out based on age, not need. A retiree who earned a respectable income over their lifetime shouldn't need Social Security to provide for their retirement. They had the means to save back enough to cover their retirement years. Such a person could easily have a million or so dollars saved up.

The obvious way to means test is...to observe your means. Look at the retiree's assets, then apply some kind of threshold at which point benefits are subtracted. (More likely a sliding scale, such that holding an extra dollar doesn't magically cause thousands of dollars worth of annual payments to disappear.) This may seem superficially fair, because such means testing would avoid the bad optics of making government welfare payments to millionaires and billionaires. But there's an obvious moral hazard problem. If saving less results in a higher Social Security income, people will be encouraged to save too little for retirement. Some people save back nothing for retirement, leaning on the lazy assumption that Social Security will be adequate to cover living expenses. (It's not for most retirees.) Means testing based on current assets would exacerbate this problem. Some fools would deliberately aim for zero assets to literally maximize Social Security. That's an extreme case, but even normal, rational people would be nudged in the direction of inadequate savings.

The smart way to means test is to count total lifetime income, not current assets at the time of retirement. Two people who have had identical incomes over their lifetime have had roughly equal opportunities to save. If one saves frugally and the other saves back nothing, we shouldn't feel compelled to help out the latter. Both people had the same lifetime means, but they made different choices for what to do with their earnings. There still may be some frugal individuals with modest incomes who retire millionaires. They may get Social Security payments because their lifetime income was low, even though they don't technically need it. And there will be people with high lifetime earnings but inadequate savings who get nothing. Hopefully, the government makes a credible commitment to not bail out these people. The best scenario is that they get the message early in their working lives that nobody is coming to save them, and that they should set aside what they'll need for their own retirement. 

This scheme mostly avoids the moral hazard problem. There might be some people who deliberately earn less over their lifetimes to game the system, but a smartly designed payment scheme would avoid any such gaming. There should be no "cliffs", whereby earning one extra dollar causes thousands of dollars of Social Security payments to disappear. And there should be no point on the sliding scale where earning a dollar in income loses you more than a dollar in Social Security payments. Social Security payments should be such a gentle slope with respect to lifetime income that there is no temptation to earn less in the marketplace. This should be easy enough to do if we think of it as a program to avoid indigence in old age, rather than a program to fund the retirements of middle-income earners. A minimalist income floor can be provided without distorting the incentives to earn and save over a lifetime. 

Medicare is a little more complicated, because it's not just an entitlement program. It vastly distorts the market for medicine by being one of the largest single payers. We would need to have pro-market reforms, whereby people get comfortable paying out of pocket for most of their medical expenses rather than having third parties pay for almost everything. Patient price shopping and transparent pricing would bring costs down and eliminate a lot of wasteful spending. But given that, the same arguments would apply. 

I think there are a couple of major barriers to this kind of reform, one ideological and one selfish (both are cynical). The selfish one is that current and near-future retirees don't want to see anything happen to a government program that they're planning to draw an income from. I think the kind of means testing I describe here wouldn't impoverish many retirees, because people with modest or high incomes typically save for retirement (beyond what they expect to collect from Social Security). Still, it would be a little unfair to change the deal on people who are in or near retirement. So a more palatable (you could even say fairer) plan would be to start the means testing on people who will be retiring more than, say ten years in the future. Means testing could be on a gradient that scales up over time, so people retiring in ten years could get essentially the same benefits as current retirees while people retiring 25 or 30 years in the future could get the full effect of means-testing. This solution is so obvious that the "It's unfair to current retirees" argument carries no water at all. We should be asking, "What's the optimal state of this welfare program? What does the transition look like if we have decades or a century to ease into it?" The specter of current retirees being left in the cold, having their incomes revoked without warning, is nothing but a scare tactic. 

The ideological opposition comes from the left's knee-jerk love of entitlement programs. They prefer to have a broad base of recipients for these programs so it becomes difficult to reform them, even if that means throwing government money at people who don't need it. They want everyone to have "buy-in" so the whole population becomes part of the program's constituency. When politicians start talking about fiscal responsibility and reigning in the unsustainable spending of Social Security and Medicare, they want boomer-cons and senior Trump voters to fight back saying, "Get your government hands off my Social Security." This dynamic serves up some delicious hypocrisy, but it also makes government transfer programs politically untouchable. It's a dishonest way to sell something to the public. If transfer programs that specifically target the needy are politically unpalatable, if the American public wouldn't vote for them or would underfund them because of a lack of buy-in, then we shouldn't have them in their current incarnation. But it looks like we're stuck with them for the long term.