2021 was the deadliest year in U.S. history, and new data and research are offering more insights into how it got that bad.
The main reason for the increase in deaths? COVID-19, said Robert Anderson, who oversees the Centers for Disease Control and Prevention’s work on death statistics.
The agency this month quietly updated its provisional death tally. It showed there were 3.465 million deaths last year, or about 80,000 more than 2020’s record-setting total.
Early last year, some experts were optimistic that 2021 would not be as bad as the first year of the pandemic — partly because effective COVID-19 vaccines had finally become available.
“We were wrong, unfortunately,” said Noreen Goldman, a Princeton University researcher.
COVID-19 deaths rose in 2021 — to more than 415,000, up from 351,000 the year before — as new coronavirus variants emerged and an unexpectedly large numbers of Americans refused to get vaccinated or were hesitant to wear masks, experts said.
The coronavirus is not solely to blame. Preliminary CDC data also shows the crude death rate for cancer rose slightly, and rates continued to increase for diabetes, chronic liver disease and stroke.
Drug overdose deaths also continued to rise. The CDC does not yet have a tally for 2021 overdose deaths, because it can take weeks of lab work and investigation to identify them. But provisional data through October suggests the nation is on track to see at least 105,000 overdose deaths in 2021 — up from 93,000 the year before.
New research released Tuesday showed a particularly large jump in overdose deaths among 14- to 18-year-olds.
Adolescent overdose death counts were fairly constant for most of the last decade, at around 500 a year, according to the paper published by the Journal of the American Medical Association. They almost doubled in 2020, to 954, and the researchers estimated that the total hit nearly 1,150 last year.
Joseph Friedman, a UCLA researcher who was the paper’s lead author, called the spike “unprecedented.”
Those teen overdose deaths were only around 1% of the U.S. total. But adolescents experienced a greater relative increase than the overall population, even though surveys suggest drug use among teens is down.
Experts attributed the spike to fentanyl, a highly lethal drug that has been cut into heroin for several years. More recently it’s also been pressed into counterfeit pills resembling prescription drugs that teens sometimes abuse.
National death trends affect life expectancy — an estimate of the average number of years a baby born in a given year might expect to live.
With rare exceptions, U.S. life expectancy has reliably inched up year after year. But the CDC’s life expectancy estimate for 2020 was about 77 years — more than a year and a half lower than what it was in 2019.
The CDC has not yet reported its calculation for 2021. But Goldman and some other researchers have been making their own estimates, presented in papers that have not yet been published in peer-reviewed journals.
Those researchers think U.S. life expectancy dropped another five or six months in 2021 — putting it back to where it was 20 years ago.
A loss of more than two years of life expectancy over the last two years “is mammoth,” Goldman said.
One study looked at death data in the U.S. and 19 other high-income countries. The U.S. fared the worst.
“What happened in the U.S. is less about the variants than the levels of resistance to vaccination and the public’s rejection of practices, such as masking and mandates, to reduce viral transmission,” one of the study’s authors, Dr. Steven Woolf of Virginia Commonwealth University, said in a statement.
Some experts are skeptical that life expectancy will quickly bounce back. They worry about long-term complications of COVID-19 that may hasten the deaths of people with chronic health problems.
Preliminary — and incomplete — CDC data suggest there were at least 805,000 U.S. deaths in about the first three months of this year. That’s well below the same period last year, but higher than the comparable period in 2020.
“We may end up with a ‘new normal’ that’s a little higher than it was before,” Anderson said.
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The Associated Press Health & Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education. The AP is solely responsible for all content.
The U.S. has ordered its consular staff to leave Shanghai, which is under a lockdown to contain a COVID-19 surge.
The State Department said the order is an upgrade from the “authorized” departure issued last week that made the decision voluntary.
The order covers “non-emergency U.S. government employees and their family members from U.S. Consulate General Shanghai.”
In its late Monday announcement, the department said, “Our change in posture reflects our assessment that it is best for our employees and their families to be reduced in number and our operations to be scaled down as we deal with the changing circumstances on the ground.”
China responded angrily to the earlier voluntary departure order.
The effort to hold drug companies, pharmacies and distributors accountable for their role in the opioid crisis has led to a whirlwind of legal activity around the U.S. that can be difficult keep tabs on.
Three trials are underway now, in Florida, West Virginia and Washington state. New legal settlements are being reached practically every week to provide governments money to fight the crisis and in some cases funds for medicines to reverse overdoses or to help with treatment. More settlements are likely on the way.
More than 3,000 lawsuits have been filed by state and local governments, Native American tribes, unions, hospitals and other entities in state and federal courts over the toll of opioids. Most allege the industry created a public nuisance in a crisis that has been linked to the deaths of 500,000 Americans over the past two decades.
Collectively, businesses have faced settlements, judgements and civil and criminal penalties totaling more than $47 billion in the last 15 years. The three main entities targeted are the companies that manufactured and sold the pills; the businesses that distributed them; and the pharmacies that dispensed them.
An overview of the litigation and settlements involving the various companies:
PURDUE PHARMA
Purdue is the maker of OxyContin, an extended-release version of oxycodone that packed higher doses into pills. The drug, released in 1996, became a heavily marketed blockbuster drug — and is associated closely with the epidemic’s first wave.
Like other opioids, it was promoted not just for post-surgery and cancer pain but for chronic pain — an area where doctors previously were reluctant to prescribe such powerful drugs.
Faced with thousands of lawsuits, the company went into bankruptcy protection in 2019 to help reach a settlement.
It calls for members of the Sackler family who own the company to give up their stakes, making way for it to become a new entity — to be known as Knoa Pharma — with profits funding the fight against the opioid crisis. Additionally, family members are to pay $5.5 billion to $6 billion over time, with a portion of the money going to individual victims.
Earlier this year, three members of the family attended an online hearing in which parents described losing children to addictions that started with OxyContin, and people recovering from addictions described their journeys.
As part of the exchange, Sackler family members would get protection from lawsuits over opioids.
For the settlement to be finalized, a higher court must overturn a judge’s ruling that threw out an earlier version of the deal. A hearing on that is scheduled for April 29 before the U.S. 2nd Circuit Court of Appeals in New York.
In the meantime, activists and some members of the U.S. Senate are asking the Justice Department to consider charges against family members.
OTHER DRUGMAKERS
In a major court victory for drugmakers last year, a California judge ruled against some local governments in their case against pharmaceutical companies Johnson & Johnson, Endo International and Teva Pharmaceutical Industries.
Some of those drugmakers — Johnson & Johnson, Allergan and Teva — are now on trial in West Virginia.
But companies have largely been settling suits.
Mallinckrodt, which was a leading producer of generic oxycodone, also used bankruptcy court to reach a settlement, agreeing to a $1.6 billion nationwide deal in 2020.
Johnson & Johnson has agreed to a $5 billion nationwide settlement. It was announced alongside a separate settlement involving the three biggest drug wholesalers. The company’s Janssen subsidiary stopped selling its fentanyl patches and pain pills in the U.S. in 2020. J&J; was also the first drugmaker to be held liable for the opioid crisis in a trial, though the Oklahoma state Supreme Court later overturned the ruling.
Endo made the opioid Opana, which was eventually removed from the market. The company has been reaching individual settlements with states. Deals since last year with Florida, New York, Texas, West Virginia and some district attorneys in Tennessee have totaled well over $200 million.
Late last year, a New York jury found Teva partly responsible for the state’s opioid crisis through its marketing of the fentanyl drugs Actiq and Fentora. Most of the other companies the state and two counties sued settled before or during a trial last year. A separate trial is to be held to determine damages.
Since the New York trial, Teva has reached settlements with Texas, Florida and Rhode Island totaling more than $250 million. It will also provide drugs to reverse overdoses and treat addictions.
Allergan, now a subsidiary of AbbVie, has been settling suits involving the extended-release morphine pill Kadian. It reached one major settlement with New York last year. Since then, it has been part of the multi-company settlements in Florida and Rhode Island.
Executives from drugmaker Insys were convicted in 2019 of bribing doctors across the U.S. to prescribe their sublingual fentanyl spray Subsys. Company founder John Kapoor was sentenced to 5 1/2 years in federal prison.
The company also paid $225 million to resolve federal investigations into allegations that it paid kickbacks and used other illegal marketing tactics.
DISTRIBUTION COMPANIES
The three big national companies — AmerisourceBergen, Cardinal Health and McKesson — finalized their settlement, worth a total of $21 billion over 18 years, in February.
The deal, combined with Johnson & Johnson’s, is expected to be the single biggest settlement between companies in the drug industry and governments.
The total amounts include separate settlements covering all federally recognized Native American tribes.
With settlement money starting to flow to state and local governments, officials are figuring out how to prioritize it. The funds are arriving at a precarious time: The number of U.S. overdose deaths from all drugs topped 100,000 in a 12-month period for the first time last year. The majority of those deaths are from opioids — and particularly illicit synthetic versions including fentanyl.
Unlike the tobacco settlements of the 1990s, there are safeguards intended to steer most of the opioid settlement funds to addressing the crisis. Public health experts have ideas for how to do that, but the decisions are up to government officials.
The distribution companies also went to trial last year in West Virginia. A judge has not yet ruled.
Pharmacy chains have been sued less often than companies that make or distribute opioids. In one groundbreaking case, a federal jury in Ohio last year found CVS, Walgreens and Walmart recklessly distributed massive amounts of pain pills in Lake and Trumbull counties.
Late last month, CVS settled in Florida. That left Walgreens to go to trial Monday.
CONSULTING COMPANY
Global consulting firm McKinsey & Company also reached deals last year with the states, Washington, D.C., and U.S. territories for advising businesses on how to sell more prescription opioids amid the overdose crisis. Those settlements totaled more than $600 million.
A group of U.S. senators is pushing for a federal investigation, saying there were conflicts when the company consulted on opioid-related issues both for companies and the U.S. Food and Drug Administration.
Total Doses Distributed = 711,815,445. Total Doses Administered = 565,945,931. Number of People Receiving 1 or More Doses = 256,266,662. Number of People Fully Vaccinated = 218,430,663.
Philadelphia became the first major U.S. city to reinstate its indoor mask mandate on Monday after reporting a sharp increase in coronavirus infections, with the city’s top health official saying she wanted to forestall a potential new wave driven by an omicron subvariant.
Confirmed COVID-19 cases have risen more than 50% in 10 days, the threshold at which the city’s guidelines call for people to wear masks indoors, said Dr. Cheryl Bettigole, the health commissioner. Health officials believe the recent spike is being driven by the highly transmissible BA.2 subvariant of omicron, which has spread rapidly throughout Europe and Asia, and has become dominant in the U.S. in recent weeks.
“If we fail to act now, knowing that every previous wave of infections has been followed by a wave of hospitalizations, and then a wave of deaths, it will be too late for many of our residents,” Bettigole said. “This is our chance to get ahead of the pandemic, to put our masks on until we have more information about the severity of this new variant.”
Most states and cities dropped their masking requirements in February and early March following new guidelines from the U.S. Centers for Disease Control and Prevention that put less focus on case counts and more on hospital capacity. The CDC said at that time that most Americans could safely take off their masks.
Philadelphia dropped its mask mandate March 2, and Bettigole acknowledged “it was wonderful to feel that sense of normalcy again.”
“I sincerely wish we didn’t have to do this again. But I am very worried about our vulnerable neighbors and loved ones,” she said.
The city is reporting more than 140 cases per day — a fraction of what it saw at the height of the omicron surge — and hospitalizations remain low at only 46 patients. About 750 Philadelphia residents died in the wintertime omicron surge, Bettigole said.
Health inspectors will start to enforce the mask mandate at city businesses starting April 18.
The restaurant industry pushed back against reimposed masking, saying workers will bear the brunt of customer anger over the new rules.
“This announcement is a major blow to thousands of small businesses and other operators in the city who were hoping this spring would be the start of recovery,” said Ben Fileccia, senior director of operations at the Pennsylvania Restaurant & Lodging Association.
Bettigole said masking will help restaurants and other businesses stay open, while a huge new wave of COVID-19 would keep customers at home.
In New York City, Mayor Eric Adams has paused his push to unwind many of the city’s virus rules as cases have risen, opting for now to keep a mask mandate for 2 to 4-year-olds in city schools and preschools. But Adams, a Democrat who has said New Yorkers should not let the pandemic run their lives, has already lifted most other mask mandates and rules requiring proof of vaccination to dine in restaurants, work out at gyms or attend shows.
Adams was asked at a virtual news conference Monday afternoon if he was considering reimposing the New York City mask mandate in light of Philadelphia’s decision. The mayor said he would listen to his team of medical doctors for their advice on whether to bring back any restrictions. Adams himself tested positive for COVID-19 on Sunday.
New York City is now averaging around 1,800 new cases per day, about three times higher than in early March when New York began easing rules. That does not include the many home tests that go unreported to health officials.
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Rubinkam reported from northeastern Pennsylvania. Associated Press reporter Michelle L. Price in New York contributed to this story.
Trial opened Monday in Florida’s opioid epidemic lawsuit against the Walgreens pharmacy chain, which state officials accuse of prioritizing profits over health by improperly dispensing millions of powerful painkillers that caused tens of thousands of deaths.
The trial, in Pasco County north of Tampa, comes after other defendants in the Florida lawsuit including the CVS drug store chain settled for an estimated $870 million. The state could seek similar massive damages from Walgreens in the jury trial expected to last a few weeks.
OxyContin maker Purdue Pharma has a tentative nationwide deal that includes $6 billion in cash from members of the Sackler family who own the company. In all, settlements, civil and criminal penalties around the country since 2007 have totaled over $45 billion, according to an Associated Press tally.
In Florida, the state’s case hinges on accusations that as Walgreens dispensed more than 4.3 billion total opioid pills in Florida from May 2006 to June 2021, more than half contained one or more easily recognized red flags for abuse, fraud and addiction that the company should have noticed and acted upon.
“The evidence will show Walgreens knowingly profited from the opioid crisis,” said attorney Jim Webster for the state in an opening statement, which was attended by Florida Attorney General Ashley Moody. “Walgreens wasn’t just greedy. It was fueling the opioid crisis that was killing people.”
Walgreens is based in Deerfield, Illinois, and operates more than 9,000 stores in all 50 states, according to the company website. About 820 of those locations are in Florida.
Walgreens attorney Steve Derringer told jurors they should focus on how manufacturers such as Purdue Pharma misled pharmacies on opioid addictive properties. He also noted that Florida did little as the opioid epidemic arose, particularly the predatory “pill mills” that proliferated in the state before a crackdown finally ended them.
“Walgreens had nothing to do with any of that,” Derringer said in his opening statement. “They (drug makers) caused this epidemic by misrepresenting the risks and benefits to pharmacies.”
The opioid epidemic has been linked to more than 500,000 deaths in the U.S. over the past two decades, counting those from prescription painkillers such as OxyContin and generic oxycodone as well as illicit drugs such as heroin and illegally produced fentanyl.
In Florida, Webster said, more than 39,000 Floridians died from opioid abuse or related problems between 1999 and 2020. Walgreens, he said, sold about one of every four opioids in the state over a similar time span often under questionable circumstances, such as a shady doctor, fake prescriptions or huge amounts of drugs obviously far in excess of what was necessary for a given patient.
“Walgreens was the last line of defense,” Webster said. “Walgreens failed its duty to investigate suspicious prescriptions.”
Florida has spent some $14 billion over the last 20 years for multiple opioid-related costs, ranging from criminal justice to drug rehabilitation for addicts to treatment for opioid-addicted infants, Webster said. The state will seek billions of dollars in damages in the Walgreens case.
In the same case, Moody said CVS Health Corp. and CVS Pharmacy Inc. will pay the state $484 million. Teva Pharmaceuticals Industries Ltd. agreed to pay $195 million and Allergan PLC more than $134 million.
Florida has previously obtained millions of dollars in opioid settlements involving McKesson Corp., Cardinal Health Inc., Johnson & Johnson Inc. and AmerisourceBergen Corp.
