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Article ; Online: The Evolution of Excess Deaths in the United States During the First 2 Years of the COVID-19 Pandemic.

Ruhm, Christopher J

2023 Volume 192, Issue 12, Page(s) 1949–1959

Abstract: Understanding consequences of the COVID-19 pandemic requires information on the excess mortality resulting from it. Multiple studies have examined excess deaths during the pandemic's initial stages, but how these have changed over time is unclear. ... ...

Abstract	Understanding consequences of the COVID-19 pandemic requires information on the excess mortality resulting from it. Multiple studies have examined excess deaths during the pandemic's initial stages, but how these have changed over time is unclear. National- and state-level death counts and population data from 2009 to 2022 were used in this analysis to evaluate excess fatalities from March 2020 to February 2021 and March 2021 to February 2022, with deaths from earlier years used to project baseline counts. The outcomes were total, group-specific, cause-specific, and age-by-cause excess fatalities, and numbers and percentages directly involving COVID-19. Excess deaths declined from 655,735 (95% confidence interval: 619,028, 691,980) during the first pandemic year to 586,505 (95% confidence interval: 532,823, 639,205) in the second. The reductions were particularly large for Hispanics, Blacks, Asians, seniors, and residents of states with high vaccination rates. Excess deaths increased from the first to second year for persons younger than 65 years and in low-vaccination states. Excess mortality from some diseases declined, but those from alcohol, drug, vehicle, and homicide causes likely increased between the first and second pandemic year, especially for prime-age and younger individuals. The share of excess fatalities involving COVID-19 decreased modestly over time, with little change in its role as an underlying versus contributing cause of death.
MeSH term(s)	Humans ; COVID-19 ; Pandemics ; United States/epidemiology ; Mortality
Language	English
Publishing date	2023-05-21
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural
ZDB-ID	2937-3
ISSN	1476-6256 ; 0002-9262
ISSN (online)	1476-6256
ISSN	0002-9262
DOI	10.1093/aje/kwad127
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Article ; Online: Pandemic And Recession Effects On Mortality In The US During The First Year Of COVID-19.

Ruhm, Christopher J

Health affairs (Project Hope)

2022 Volume 41, Issue 11, Page(s) 1550–1558

Abstract: There were almost 700,000 excess deaths in the US from March 1, 2020, through February 28, 2021, resulting from two often counterbalancing mechanisms: those predicted by changes in unemployment rates occurring during this period, referred to here as the " ...

Abstract	There were almost 700,000 excess deaths in the US from March 1, 2020, through February 28, 2021, resulting from two often counterbalancing mechanisms: those predicted by changes in unemployment rates occurring during this period, referred to here as the "recession effect," and those predicted by the "pandemic effect," which reflects direct consequences of SARS-CoV-2 infections and COVID-19, accompanying impacts on health and medical care, and other changes in mortality not caused by greater joblessness. Using data from the Centers for Disease Control and Prevention, this study decomposed total mortality in this period into pandemic and recession effects, with additional estimates by sex, race and ethnicity, age, and fourteen causes. Although the pandemic effect increased many types of mortality, the recession effect reduced most types of mortality. Without the recession effect, there would have been nearly 40,000 more deaths than actually occurred. However, there were disparate impacts, particularly for external causes. Vehicular and alcohol-related fatalities and homicides rose because of strong pandemic effects. In contrast, the recession effect accounted for a greater share of the rise in drug mortality. Offsetting pandemic and recession effects resulted in a decrease in the number of suicides. Understanding these diverse impacts provides useful lessons for policy efforts to mitigate the current and future health pandemics.
MeSH term(s)	Humans ; Pandemics ; COVID-19 ; SARS-CoV-2 ; Cause of Death ; Suicide ; Mortality
Language	English
Publishing date	2022-11-02
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural
ZDB-ID	632712-6
ISSN	1544-5208 ; 0278-2715
ISSN (online)	1544-5208
ISSN	0278-2715
DOI	10.1377/hlthaff.2022.00364
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Article ; Online: Excess deaths in the United States during the first year of COVID-19.

Ruhm, Christopher J

Preventive medicine

2022 Volume 162, Page(s) 107174

Abstract: Accurately determining the number of excess deaths caused by the COVID-19 pandemic is hard. The most important challenge is determining the counterfactual count of baseline deaths that would have occurred in its absence. Flexible estimation methods were ... ...

Abstract	Accurately determining the number of excess deaths caused by the COVID-19 pandemic is hard. The most important challenge is determining the counterfactual count of baseline deaths that would have occurred in its absence. Flexible estimation methods were used here to provide this baseline number and plausibility of the resulting estimates was evaluated by examining how changes between baseline and actual prior year deaths compared to historical year-over-year changes during the previous decade. Similar comparisons were used to examine the reasonableness of excess death estimates obtained in prior research. Total, group-specific and cause-specific excess deaths in the U.S. from March 2020 through February 2021 were calculated using publicly available data covering all deaths from March 2009 through December 2020 and provisional data for January 2021 and February 2021. The estimates indicate that there were 649,411 (95% CI: 600,133 to 698,689) excess deaths in the U.S. from 3/20-2/21, a 23% (95% CI: 21%-25%) increase over baseline, with 82.9% (95% CI: 77.0% - 89.7%) of these attributed directly to COVID-19. There were substantial differences across population groups and causes in the ratio of actual-to-baseline deaths, and in the contribution of COVID-19 to excess mortality. Prior research has probably often underestimated baseline mortality and so overstated both excess deaths and the percentage of them attributed to non-COVID-19 causes.
MeSH term(s)	COVID-19 ; Humans ; Mortality ; Pandemics ; United States/epidemiology
Language	English
Publishing date	2022-07-22
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural
ZDB-ID	184600-0
ISSN	1096-0260 ; 0091-7435
ISSN (online)	1096-0260
ISSN	0091-7435
DOI	10.1016/j.ypmed.2022.107174
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Article ; Online: Marijuana legalization and opioid deaths.

Mathur, Neil K / Ruhm, Christopher J

Journal of health economics

2023 Volume 88, Page(s) 102728

Abstract: Many states have legalized marijuana over the last two decades, initially for medical purposes and more recently for recreational consumption. Despite prior research, it remains unclear how these policies are related to rates of opioid-involved overdose ... ...

Abstract	Many states have legalized marijuana over the last two decades, initially for medical purposes and more recently for recreational consumption. Despite prior research, it remains unclear how these policies are related to rates of opioid-involved overdose deaths, which have trended rapidly upwards over time. We examine this question in two ways. First, we replicate and extend previous investigations to show that the prior empirical results are frequently fragile to the choice of specifications and time periods, and probably provide an overly optimistic assessment of the effects of marijuana legalization on opioid deaths. Second, we present new estimates suggesting that legal medical marijuana, particularly when available through retail dispensaries, is associated with higher opioid mortality. The results for recreational marijuana, while less reliable, also indicate that retail sales may be correlated with greater death rates relative to the counterfactual of no legal cannabis. A likely mechanism for these effects is the emergence of illicit fentanyl, which has increased the riskiness of even small positive effects of cannabis legalization on the consumption of opioids.
MeSH term(s)	Humans ; Cannabis ; Analgesics, Opioid/adverse effects ; Legislation, Drug ; Medical Marijuana/adverse effects ; Commerce
Chemical Substances	Analgesics, Opioid ; Medical Marijuana
Language	English
Publishing date	2023-01-06
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	625797-5
ISSN	1879-1646 ; 0167-6296
ISSN (online)	1879-1646
ISSN	0167-6296
DOI	10.1016/j.jhealeco.2023.102728
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Article ; Online: Estimating Drug Involvement in Fatal Overdoses With Incomplete Information.

Drake, Keith M / Ruhm, Christopher J

American journal of preventive medicine

2023 Volume 65, Issue 6, Page(s) 1172–1180

Abstract: Introduction: Death certificates provide incomplete information on the specific drug categories involved in fatal overdoses. The accuracy of previously developed corrections for this and modifications to them was examined. Uncorrected mortality rates ... ...

Abstract	Introduction: Death certificates provide incomplete information on the specific drug categories involved in fatal overdoses. The accuracy of previously developed corrections for this and modifications to them was examined. Uncorrected mortality rates were compared with rates from the preferred correction models. Methods: Data were obtained for the universe of 932,364 drug overdoses in the U.S. between 1999 and 2020, including 769,982 (82.6%) with a drug classification and 162,382 (17.4%) without, from the National Center for Health Statistics Multiple Cause of Death files. Opioid and cocaine involvement for unclassified overdoses were estimated using multiple approaches. Prediction accuracy was assessed as the mean absolute deviation between actual and estimated involvement for a test sample with known drug involvement. Corrected death rates from preferred models were compared with uncorrected rates. Analyses were conducted in 2022-2023. Results: Previous regression-based corrections that controlled for decedent characteristics can be improved upon by adding state-fixed effects as covariates. Once this is done, supplementary controls for county characteristics or contributory causes of death do not materially improve prediction accuracy. Properly designed naïve models, which distribute unspecified drug deaths proportionately to specified deaths, often provide similar results and, for county-level analyses, supply the most accurate predictions. Uncorrected results substantially understate the levels of opioid and cocaine involvement and can either understate or overstate changes over time. Conclusions: Failing to correct for incomplete information on death certificates leads to inaccurate counts of deaths from specific categories of drugs, such as opioids. However, relatively simple corrections are available that substantially improve accuracy.
MeSH term(s)	United States/epidemiology ; Humans ; Analgesics, Opioid ; Cocaine ; Drug Overdose
Chemical Substances	Analgesics, Opioid ; Cocaine (I5Y540LHVR)
Language	English
Publishing date	2023-07-05
Publishing country	Netherlands
Document type	Journal Article
ZDB-ID	632646-8
ISSN	1873-2607 ; 0749-3797
ISSN (online)	1873-2607
ISSN	0749-3797
DOI	10.1016/j.amepre.2023.06.019
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Article ; Online: Commentary on Boslett et al. (2020): Towards better measurement of drug involvement in fatal overdoses.

Ruhm, Christopher J

Addiction (Abingdon, England)

2020 Volume 115, Issue 7, Page(s) 1318–1319

MeSH term(s)	Analgesics, Opioid ; Cause of Death ; Death Certificates ; Drug Overdose ; Humans ; Opioid-Related Disorders
Chemical Substances	Analgesics, Opioid
Language	English
Publishing date	2020-02-27
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't ; Comment
ZDB-ID	1141051-6
ISSN	1360-0443 ; 0965-2140
ISSN (online)	1360-0443
ISSN	0965-2140
DOI	10.1111/add.14988
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Article ; Online: Nonopioid Overdose Death Rates Rose Almost As Fast As Those Involving Opioids, 1999-2016.

Ruhm, Christopher J

Health affairs (Project Hope)

2019 Volume 38, Issue 7, Page(s) 1216–1224

Abstract: The number of Americans dying from drug overdoses has risen rapidly, but the contribution of nonopioid drugs to this growth is not well understood. Using vital statistics data from the universe of deaths among US residents in the period 1999-2016, I ... ...

Abstract	The number of Americans dying from drug overdoses has risen rapidly, but the contribution of nonopioid drugs to this growth is not well understood. Using vital statistics data from the universe of deaths among US residents in the period 1999-2016, I calculated levels of and increases in overall nonopioid fatal overdose rates and those for subgroups stratified by manner of death, sex, race/ethnicity, and age. Mortality rates were also calculated separately for sedatives, stimulants, antidepressants, and cocaine. Recently developed methods were used to correct for the incomplete reporting of drug involvement on death certificates. From 1999 to 2016 the number of nonopioid drug deaths rose 274 percent, and deaths per 100,000 population rose by 223 percent. Over the same period, opioid-involved fatality counts and rates grew by 371 percent and 307 percent, respectively. Fatal overdose rates involving stimulants increased more than tenfold, with slower growth but higher rates for deaths involving sedatives and cocaine. Midlife non-Hispanic whites generally experienced the highest levels and rise in nonopioid death rates, but cocaine fatality rates were particularly common among nonwhite or Hispanic males ages 40-59. Policies designed to curb the opioid epidemic are probably helpful in reducing nonopioid deaths, but targeted interventions may also be needed.
MeSH term(s)	Adult ; African Continental Ancestry Group/statistics & numerical data ; Analgesics, Opioid/poisoning ; Antidepressive Agents/poisoning ; Cause of Death/trends ; Central Nervous System Stimulants/poisoning ; Drug Overdose/epidemiology ; Drug Overdose/mortality ; European Continental Ancestry Group/statistics & numerical data ; Female ; Hispanic Americans/statistics & numerical data ; Humans ; Hypnotics and Sedatives/poisoning ; Male ; Middle Aged ; United States/epidemiology
Chemical Substances	Analgesics, Opioid ; Antidepressive Agents ; Central Nervous System Stimulants ; Hypnotics and Sedatives
Language	English
Publishing date	2019-06-26
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	632712-6
ISSN	1544-5208 ; 0278-2715
ISSN (online)	1544-5208
ISSN	0278-2715
DOI	10.1377/hlthaff.2018.05522
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Article ; Online: Drivers of the fatal drug epidemic.

Ruhm, Christopher J

Journal of health economics

2019 Volume 64, Page(s) 25–42

Abstract: This study examines the contributions of the medium-run evolution of local economies and of changes in the "drug environment' in explaining county-level changes in drug and related mortality rates from 1999 to 2015. A primary finding is that drug ... ...

Abstract	This study examines the contributions of the medium-run evolution of local economies and of changes in the "drug environment' in explaining county-level changes in drug and related mortality rates from 1999 to 2015. A primary finding is that drug mortality rates did increase more in counties experiencing relative economic decline than in those with more robust growth, but that the relationship is weak and mostly accounted for by confounding factors. In the preferred estimates, less than one-tenth of the rise in drug and opioid-involved fatality rates is explained and the contribution is even smaller, quite possibly zero, when allowing for plausible selection on unobservables. Conversely, the risk of drug deaths varies systematically over time across population subgroups in ways that are consistent with an important role for the public health environment related to the availability and cost of drugs. In particular, the relative risk and share of drug mortality increased rapidly for males and younger adults, compared to their counterparts, when the primary driver of the fatal drug epidemic transitioned from prescription to illicit opioids. These results suggest that efforts to improve local economies, while desirable for other reasons, are not likely to yield significant reductions in overdose mortality, but with greater potential for interventions directly addressing the drug environment.
MeSH term(s)	Adolescent ; Adult ; Analgesics, Opioid/administration & dosage ; Analgesics, Opioid/adverse effects ; Drug Overdose/mortality ; Female ; Humans ; Male ; Middle Aged ; Substance-Related Disorders/epidemiology ; Substance-Related Disorders/etiology ; Substance-Related Disorders/mortality ; United States/epidemiology ; Young Adult
Chemical Substances	Analgesics, Opioid
Language	English
Publishing date	2019-01-14
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	625797-5
ISSN	1879-1646 ; 0167-6296
ISSN (online)	1879-1646
ISSN	0167-6296
DOI	10.1016/j.jhealeco.2019.01.001
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Article ; Online: Has mortality risen disproportionately for the least educated?

Leive, Adam A / Ruhm, Christopher J

Journal of health economics

2021 Volume 79, Page(s) 102494

Abstract: We examine whether the least educated population groups experienced the worst mortality trends at the beginning of the 21st century by measuring changes in mortality across education quartiles. We document sharply differing gender patterns. Among women, ... ...

Abstract	We examine whether the least educated population groups experienced the worst mortality trends at the beginning of the 21st century by measuring changes in mortality across education quartiles. We document sharply differing gender patterns. Among women, mortality trends improved fairly monotonically with education. Conversely, male trends for the lowest three education quartiles were often similar. For both sexes, the gap in mortality between the top 25 percent and the bottom 75 percent is growing. However, there are many groups for whom these patterns are reversed - with better experiences for the less educated - or where the differences are statistically indistinguishable.
MeSH term(s)	Educational Status ; Female ; Gender Identity ; Humans ; Male ; Mortality
Language	English
Publishing date	2021-07-09
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	625797-5
ISSN	1879-1646 ; 0167-6296
ISSN (online)	1879-1646
ISSN	0167-6296
DOI	10.1016/j.jhealeco.2021.102494
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Article ; Online: Federal Opioid Grant Funding Favors Least Populous States, Not States With Greatest Need.

Katcher, Bradley A / Ruhm, Christopher J

Health affairs (Project Hope)

2021 Volume 40, Issue 5, Page(s) 829–836

Abstract: The federal government provides grants to states to assist with their efforts to ameliorate the opioid epidemic. However, it is not currently understood how well these funds are targeted toward the areas with the greatest need. To address this, we ... ...

Abstract	The federal government provides grants to states to assist with their efforts to ameliorate the opioid epidemic. However, it is not currently understood how well these funds are targeted toward the areas with the greatest need. To address this, we constructed a database of federal grants addressing opioid and other substance use problems and investigated how closely grant dollars awarded in fiscal years 2017 and 2018 aligned with the severity of state opioid problems. Using our preferred measure, roughly one-sixth of funds, totaling $1.5 billion, would need to have been reallocated to provide equal opioid severity-adjusted funding across states; less populous states were typically the most generously funded. Grant targeting could be improved with more rigorous efforts to account for geographic differences in the severity of opioid problems. We identify problems in some frequently used targeting benchmarks, where state prevalence rates are measured with low precision.
MeSH term(s)	Analgesics, Opioid ; Financial Management ; Financing, Government ; Humans ; United States
Chemical Substances	Analgesics, Opioid
Language	English
Publishing date	2021-05-03
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	632712-6
ISSN	1544-5208 ; 0278-2715
ISSN (online)	1544-5208
ISSN	0278-2715
DOI	10.1377/hlthaff.2020.01656
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