It’s The Fall That’ll Kill You (October 2018)

How The Gap in Life Expectancy Between Whites and Blacks Finally Disappeared

Looking back on a life dotted with high-profile addiction struggles and more relationship drama than a season of The Bachelor, legendary rocker Stevie Nicks claims that there’s only one thing that she would take back: the day her psychiatrist prescribed her clonazepam. Nicks was fresh off an otherwise successful cocaine rehab, and was given the medication to help settle her nerves. She was only supposed to take it for a few weeks. It ended up dominating her life for eight years, bottoming out with a harrowing 47 days of detox. “It was like someone opened up a door and pushed me into hell,” she recalls.

Clonazepam is in a class of medications called benzodiazepines that are FDA-approved to help manage conditions like alcohol withdrawal, insomnia and panic and anxiety disorders. Benzos have been around for decades — Mick Jagger famously dubbed them “Mother’s Little Helpers” — but their use has exploded in recent years: between 1996 and 2013 the volume of pills prescribed more than tripled, which no less an authority than the New England Journal of Medicine has called “America’s other prescription drug problem”. The concern is easy to understand. Benzos work best when they’re taken intermittently or for short stretches; anything beyond that dampens their effectiveness and triggers a serious risk of addiction. Basically, like any other medication, benzodiazapenes follow the law of diminishing returns: beyond a certain point, they’re more likely to hurt than help.

As a group, elderly patients are probably already past that rubicon. Older people tend to metabolize benzos differently, which is to say not as well, as their younger counterparts. That heightens the risk of side effects like dizziness and suppressed breathing, especially when combined with opioids or alcohol. Geriatricians long ago sounded the alarm, and have even gone as far as to classify benzos as “inappropriate” for senior citizens. But their warnings have mostly fallen on deaf ears: the number of primary care visits that resulted in a benzo prescriptions increased by 57% between 2005 and 2012, and close to ten percent of Americans between 65 and 80 report taking benzos. More than half of those ended up taking the drugs for prolonged periods. Maybe America’s “other prescription drug epidemic” would be more accurate.

Yet, somehow the black community has remained relatively immune. The discrepancy is actually an all-ages affair: white patients, for instance, are overall about 2.5 times more likely than blacks to be given benzodiazipenes after being discharged from the hospital. Race-driven benzo prescription patterns echo the ongoing practice of underprescribing pain medication to black patients, which, at least in some cases, is exacerbated by healthcare workers endorsing ancient biological fictions — like the claim that black people have thicker skin and less sensitive nervous systems — that read more like Onion article musings than modern medical science.

Similarly, the difference in benzo prescriptions seems to extend from the arbitrary assumption that blacks are particularly prone to drug addiction or abuse, a charge that’s apparently impervious to exculpatory data (the rates of prescription drug abuse for blacks and whites are actually within a tenth of a percentage point of each other). In both cases, the most charitable interpretation is that doctors are trying to save black patients from drugs and side-effects that they don’t really need. The alternative explanations are, to put it mildly, not a good look.

But in the end it doesn’t so much matter whether these discrepancies are the products of out-and-out racism or just well-meaning attempts at cultural competence gone awry. The point is that, in the aggregate, these biases can reshape entire populations. Here’s an example: Life expectancy is probably the simplest measure of the health outcomes experienced by different races. Last year, the average life expectancy for black Americans was 77.5, about 3.5 years shorter than for whites. That gap is the sum of a series of maladies that disproportionately befall African-Americans: infant mortality for newborns, gun violence among youths and chronic disease into middle age. But then a funny thing happens around age 65. Among people who make it that far (congratulations, by the way), blacks tend to live longer than whites — in any given year, a white senior citizen is 2.6% more likely to die than her same-aged black neighbor.

It’s a bit of a puzzle. Why would whites have lower mortality than blacks at every stage of life, only for the numbers to flip in the golden years? It’s not as if elderly blacks suddenly become less prone to cancer, strokes and diabetes, the scourges that largely account for increased black mortality in middle age. In fact, blacks still outpace whites in terms of the 65 and over death rates as a result of those illnesses. So what gives?

As it happens, the difference is mostly wrapped up in what the Centers for Disease Control calls “unintentional injury”. Think car crashes, fires, poisonings and the like. Mortality from these accidents is 39% higher for older whites than blacks; and nearly all of that difference comes from the almost three-fold black-white discrepancy in deaths due to falls. Benzodiazepines seem to be the missing link. Doctors are rightfully wary of conflating correlation and causation, but it’s pretty well-accepted that benzo use, especially by the elderly, causes falls; our best guess is that they raise the odds of a fall by between 40% and 70%. Then add in the fact that benzo use is more than twice as common among whites. The math checks out.

In any case, falls are a big deal. A tumble that would be a mere nuisance for young adults is downright treacherous for the AARP set. A broken hip, or worse yet, a brain bleed, can easily touch off a spiral that ends in the patient’s demise. That this happens so often — and with such an overwhelming racial skew — is enough to make a noticeable impact on elderly death rates.

Even more incredibly, it’s also managed to accomplish what decades of public health programs and equal rights initiatives haven’t: bringing black and white health outcomes into parity.

Which, obviously, is a pyrrhic victory. The death rates didn’t converge because blacks are living longer. Falls are just killing enormous numbers of elderly whites. That’s not to say that whites (or blacks) are being prescribed the wrong quantity of benzos; the quality of life improvements associated with these drugs might well outweigh the increased mortality. It’s impossible to say. Really, the optimal balance is probably somewhere in the middle, with both groups being at least somewhat mismanaged. Regardless, it’s a distillation of the fundamental frustration of the American healthcare system: there’s an unparalleled bounty of resources that we can’t quite manage to deliver to the right people.

Stevie Nicks was only in her thirties when she started her clonazepam misadventure, but still had to learn the hard way that the mere availability of top notch healthcare doesn’t always translate to great outcomes. It took her nearly a decade to cut through the dissonance. “I didn’t really understand right up until the end that it was the [clonazepam] that was making me crazy,” she lamented. “I really didn’t realize it was that drug because I was taking it from a doctor and it was prescribed.”