Suicide and the Opioid Overdose Epidemic
June 1, 2018
A recent spot on NPR, an interview with an author expert in the history of opioid abuse, stated that every day 115 Americans die from opioid overdose. That seemed low to us at the JKMF in comparison to suicide deaths. Indeed it is. In 2016, 123 people died by suicide every day in America. Yet the press is all about opioids, not about suicide. But it isn’t that simple. A recent article in the New England Journal of Medicine, paraphrased below, explains.
“As the toll of opioid-overdose deaths in the United States rises, we face an urgent need for prevention. But preventing such deaths will require a better understanding of the diverse trajectories by which overdoses occur, including the distinction between intentional (suicide) and unintentional (accidental) deaths, be they in patients with chronic pain who overdose on their opioid analgesics or in those with a primary opioid use disorder (OUD). Interventions to prevent overdose deaths in suicidal people will differ from interventions targeted at accidental overdoses. Yet most strategies for reducing opioid-overdose deaths do not include screening for suicide risk, nor do they address the need to tailor interventions for suicidal persons. Moreover, the inaccuracy of available data on the proportion of suicides among opioid-overdose deaths — which are frequently classified as “undetermined” if there is no documented history of depression or a suicide note — hinders deployment of appropriate prevention services.
In 2016, the Centers for Disease Control and Prevention (CDC) reported 42,000 opioid-overdose fatalities, including an unknown number of suicides. Notably, two populations that are more likely than others to receive opioid prescriptions — patients with chronic pain and those with mood disorders — are also at greater risk for suicide. Patients with a substance use disorder are at increased risk for suicide as well, and although opioid overdoses are uncommon among suicide attempts in such patients, suicides by poisoning are far from rare. Difficulties in ascertaining the manner of death probably result in the underreporting of opioid-overdose deaths as suicides.
Of the estimated 44,965 suicides in the United States in 2016, about 50% were carried out by firearm and about 15% by drug overdose, according to the CDC. The proportion of suicides that were opioid overdoses rose from 2.2% to 4.3% between 1999 and 2014, with the highest increases occurring among people 45 to 64 years of age. On the other hand, 17% of drug-related deaths (all drugs, not only opioids) in 2010 were classified as suicides. Similarly, an analysis of opioid-overdose deaths in Utah in 2008 and 2009 showed that 21% of 2086 such deaths were attributed to suicide and 16% were classified as undetermined. Even people deemed to have died of an “unintentional overdose” frequently had suicide risk factors: depression, substance use disorders, and financial problems. Among those who died from an overdose of an illicit drug (including opioids), the age-adjusted rate of intentional overdose (suicide) increased by 61% in urban areas and 84% in nonurban areas between 1999 and 2015. Nonetheless, the percentage of the estimated 42,000 opioid-overdose deaths in 2016 that were suicides is not well documented.
One challenge in determining the manner of death in opioid-overdose fatalities is that the medical examiner or coroner cannot know the decedent’s intent with certainty. Absent a suicide note, determinations are based on autopsy, information collected at the scene of death, and circumstantial evidence. Indeed, percentages of overdose deaths classified as undetermined vary greatly from state to state.
At the same time, data from multiple sources strongly suggest that the proportion of opioid-overdose deaths that are suicides is considerable. A study of nearly 5 million veterans using National Death Index data and treatment data from electronic health records found that diagnoses of any substance use disorder were associated with increased suicide risk. Among persons with OUD, the suicide risk was 87 in 100,000 — six times the general U.S. population rate of 14 in 100,000; even after controlling for other suicide risk factors such as coexisting psychiatric diagnoses, OUD more than doubled the risk of suicide among women and increased the risk among men by 30%.
These data suggest that the true proportion of suicides among opioid-overdose deaths is somewhere between 20% and 30%, but it could be even higher.
What can be done? Certainly, efforts are afoot to change opioid prescription practices and to expand medication treatment, and such efforts should be energetically pursued. In addition, we could tailor interventions to reduce opioid-overdose deaths more effectively by pursuing policy interventions such as implementing the CDC’s recommendations for determining the manner of death; educating clinicians about the need to screen for suicide risk in patients with conditions for which opiates are prescribed, especially chronic pain, and in those with a substance use disorder; and standardizing screening for suicide risk and for treatment referral among emergency department patients who have overdosed.
Educational campaigns to increase public awareness of suicide risk could engage family and friends in interventions to prevent suicidal overdoses by seeking medical assistance. Campaigns to reduce the double stigma associated with suicide and drug addiction might make patients more willing to seek treatment. Finally, research aimed at the development and validation of screening tools to help characterize suicide risk along a continuum of awareness regarding suicidal intent would improve identification of persons who are at greater risk.
The significant increases in both opioid-overdose deaths and suicide rates in our country have contributed to reduced life expectancy for Americans. These two epidemics are intermingled, and solutions to address the opioid crisis require that we tailor interventions to preventing opioid-overdose deaths due to suicidal intent.”