Death rates among middle-aged white Americans have risen dramatically since 1999, especially for those with low levels of education.

Two Princeton University economists say this is driven mainly by deaths due to drug overdoses, suicide, and liver diseases related to alcohol — what they call “deaths of despair.”

In particular, this group of Americans has been hit hard by the opioid epidemic — both from prescription and illegal opioids.

This has led to midlife mortality rates for working class Americans overtaking those of minority groups for the first time.

In a new paper, Princeton University’s Angus Deaton and Anne Case suggest that a “cumulative disadvantage” has kept middle-aged whites in a downward spiral since the late 1990s.

“Ultimately, we see our story as about the collapse of the white, high school educated, working class after its heyday in the early 1970s, and the pathologies that accompany that decline,” they write in the report.

Read more: More white people are dying at middle age »

Rising mortality rates

Rising mortality rates among middle-aged whites are unusual in that they follow a century of declining rates.

The trend is also unique to this segment of the population. Since 1999, Americans in other groups — based on age, race, or ethnicity — have all experienced improvements in mortality.

Deaths rates among middle-aged whites with less than a high school degree are rising the quickest and much faster than middle-aged whites with at least a four-year college degree.

Recent news reports sometimes focus on the impact of “deaths of despair” in rural areas.

But Case and Deaton found that these conditions are now much more widespread.

In 2000, the “deaths of despair” epidemic among whites was centered in the Southwest. By the mid-2000s, it had spread to Appalachia, Florida, and the West Coast.

Now it pervades all areas of the country, both rural and urban.

Middle-aged whites have also lost ground against heart disease, with declines in mortality slowing over the past decade and even stopping recently.

Some blame the slowing progress against heart disease on the obesity epidemic. But it is not that simple.

Case and Deaton write that obesity is rising faster among African-Americans than whites. In spite of that, African-Americans made more progress against heart disease between 1999 and 2015.

The researchers suggest that some deaths attributed to heart disease may actually be due to type 2 diabetes, which is also associated with obesity.

Read more: Rural America’s poor health »

Cumulative disadvantages in life

While the researchers focused on mortality rates since the late 1990s, they also pointed out longer trends for whites.

The rate of “deaths of despair” for whites born in 1975 is rising faster than for those born in 1935.

Unemployment has also increased with each successive age group of whites since that time, while marriage rates have gone down. Self-reported physical pain and poor physical and mental health have gone up.

The researchers write that others have suggested that “slowly growing, stagnant, and even declining incomes” have contributed to the high mortality rates of middle-aged whites.

However, middle-aged African-Americans and Hispanics have fared little better in terms of income while their mortality has been falling over the past decade.

The “cumulative disadvantage” in life faced by whites fits with some theories suggesting that a rise in “deaths of despair” is driven by an erosion of this group’s social and economic well-being over the past two decades.

“It’s quite possible that some of the social adversities that middle-aged white men have been facing in the country over the last 20 years are having an impact on their health outcomes, including their use of substances and their vulnerability to poor outcomes,” Dr. Itai Danovitch, chair and associate professor of the Department of Psychiatry and Behavioral Neurosciences at Cedars-Sinai Medical Center, told Healthline.

Read more: Why rural hospitals are closing »

Growing deaths of despair

Given the circumstances faced by this group, “deaths of despair” may be an especially apt phrase for these preventable conditions.

“There’s probably an element of both alcohol and opioids that involves self-medicating,” said Danovitch. “And when you think about what self-medication is about, it’s often about trying to fill a hole or treat an emotional pain, or deal with despair.”

These conditions also overlap, with each fueling and feeding on the others.

“Alcohol use is associated with increased suicides. And suicides are also associated with alcohol use. And mental health problems are common to all three of those conditions,” said Danovitch.

Related mental health problems can happen not only when people are in the depths of a substance use disorder, but also when they are trying to “go straight.”

“Opioids and alcohol are really profound addictions that come with very difficult withdrawal symptoms — the kind of despair that is often associated with suicide,” Kevin Doyle, EdD, LPC, LSATP, a professor in the counselor education program at Longwood University in Virginia, told Healthline.

Complicating the matter, people also vary in how they end up with a substance abuse disorder.

“Some people are depressed, and drugs and alcohol start out as a way to help them cope,” Deni Carise, PhD, chief clinical officer for Recovery Centers of America, told Healthline.

Other people, she said, start using drugs and alcohol to have fun. And it becomes “such a problem that they’ve now either altered their brain chemistry so that they are depressed, or they are depressed situationally.”

The effects of substance abuse can also spill over into other areas of a person’s life, feeding the sense of “despair.”

With substance abuse, “there’s lots of family and financial ruin, involvement in the criminal justice system, etc.,” said Doyle, “the kinds of things that might cause someone to lose hope and get to that point of taking their own life.”

Read more: The best ways to treat opioid addictions »

Opioid epidemic still growing

The opioid epidemic, in particular, is a strong push behind rising “deaths of despair” mortality rates for middle-aged whites.

According to the Centers for Disease Control and Prevention (CDC), more than six out of 10 drug overdose deaths in the United States are due to opioids. Nearly half of these involve a prescription opioid, such as methadone, OxyContin, and Vicodin.

This includes both intentional and unintentional overdoses. Not everyone who dies of an overdose is addicted.

Among people who died from a prescription opioid overdose between 1999 and 2014, overdose rates were higher among whites, American Indians and Alaskan Natives, compared to African-Americans and Hispanics.

A recent study in JAMA Psychiatry also found that between 2001 and 2013, heroin use increased more in whites than in other racial and ethnic groups.

In addition, the proportion of people reporting that they started using prescription opioids for recreational purposes before moving onto heroin increased more for whites.

As a “gateway drug,” prescription opioids have been frighteningly effective.

“It used to be that by the time somebody comes into treatment for heroin problems, they have what we would call a 10- or 20-year drug use history or career,” said Carise.

But now, people who try a prescription opioid pill at a party or lift one from a friend’s medicine cabinet, can quickly move onto heroin, methadone, or fentanyl, a synthetic opioid.

“We have this very short trajectory now, that I’ve never seen in 30 years,” said Carise. “Sometimes in three, six, nine months easy, they’re using heroin because it’s easier to get, it’s stronger, and it’s less expensive.”

Given the complex factors behind the rise in “deaths of despair” among whites, Case and Deaton write that it “will take many years to reverse the mortality and morbidity increase.”

This may not bode well for whites who are in midlife right now — they are “likely to do much worse in old age than those currently older than 65,” write the researchers.

Counteracting this epidemic will take a comprehensive public health approach, one that addresses both the economic and social factors.

It will also mean helping people before they reach middle age — maybe even as early as public school.

We need to “empower people’s ability to recover when they hit adversity,” said Danovitch, “to be resilient, and to be healthy, and to have lives that have well-being and quality.”

Read more: Government Taking Action Against Opioid Epidemic »