September is National Suicide Prevention Awareness Month. In observance, our two institutes, the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH), are taking this opportunity to highlight a dimension of the opioid crisis that receives too little attention—the links between opioid use, opioid use disorder (OUD), and suicide.
We’ve heard a lot about the opioid epidemic, and the rising toll it is taking on our communities. In 2017, 47,600 people died from overdoses involving prescription or illicit opioids. But the opioid overdose epidemic is not limited to people with opioid addiction who accidentally take too much of a pain reliever or unknowingly inject a tainted heroin product. Concealed in the alarming number of overdose deaths is a significant number of people who have decided to take their own life.
It can be challenging to discover the true relationship between suicide and drug use. In the absence of a suicide note, it is difficult to assess the intentions of an individual who has died of an overdose, other than circumstantially. Also, the intentions of someone with OUD who overdoses may not always be clear-cut. In a study last year of current and past overdose experiences among patients seeking treatment in a Flint, Michigan emergency department, 39% of those whose worst overdose had involved an opioid or sedative reported wanting to die or not caring about the risks; another 15% reported they were unsure of their intentions.
While we don’t know exactly how many opioid overdose deaths are actually suicides, some experts estimate that up to 30% of opioid overdoses may fit this description. The connection between opioid overdose and suicide has appeared to increase over time, with one 2017 analysis of National Vital Statistics data showing significant increases in suicides involving opioids among all age groups except teens and young adults between 1999 and 2014; in those aged 55-64, the rate quadrupled.
Research seeking to understand the link between suicide and opioid use suggests the two may be entangled in multiple ways and for many reasons. A 2017 study using national survey data showed that people who misused prescription opioids were 40-60% more likely to have thoughts of suicide, even after controlling for other health and psychiatric conditions. People with a prescription opioid use disorder were also twice as likely to attempt suicide as individuals who did not misuse prescription opioids.
People with substance use disorders also frequently have other psychiatric disorders—for example, they are twice as likely to have mood and anxiety disorders, which are independently associated with increased suicide risk. The reverse is also true. Half of all individuals with a mental illness will—at some point in their life—have a substance use disorder. Moreover, mental illnesses are also associated with accidental overdoses of medications and illicit drugs.
Pain is another important factor when considering the complex relationships between opioids, overdose (both suicidal and accidental), and mental illnesses. Individuals suffering from chronic pain conditions—the primary reason people are prescribed opioids—may also have comorbid depression or other mental illnesses, and they may be at increased risk of suicide simply because of their pain. Individuals who take higher quantities of prescribed opioids for pain are also at an increased risk of accidental overdose death. With current initiatives to reduce opioid prescribing, many pain patients find themselves either unable to get treatment they need or stigmatized as “addicts” by the healthcare system, compounding their difficulties.
Our Institutes are engaged in research initiatives that address the suicide component of the opioid crisis. NIDA funds research aimed at understanding the complexities of addiction, including co-occurring mental health problems and shared environmental and genetic risk factors for addiction and mental illness. NIMH funds research aimed at understanding the causes of suicide and suicidal ideation and seeks to develop new prevention and treatment interventions specifically targeting suicide.
The opioid crisis and the deaths of despair associated with it demand addressing the larger mental health context of opioid use and misuse. We must fully utilize the effective OUD medications at our disposal in addition to addressing the many risk factors for suicide, particularly co-occurring mental illness and pain, in those who use opioids. This is why the NIH HEAL (Helping to End Addiction Long-termSM) Initiative is so important. The initiative builds upon well-established NIH research to improve prevention and treatment for opioid misuse and addiction. It also aims to enhance pain management by developing effective but safer substitutes for opioids.
As part of this initiative, participating NIH Institutes will be funding clinical trials of collaborative care models to treat people with opioid use disorder and co-occurring mental illnesses. Collaborative care models, which involve mental health professionals, care managers, and primary care physicians all working together, are already recommended for depression and post-traumatic stress disorder. Recent evidence suggests they could be effective for substance use disorders and for reducing suicide risk. These new grants aim to demonstrate this efficacy definitively and to show how collaborative care can be implemented in community health centers in the areas hardest hit by the twin epidemics of opioid overdose and suicide deaths.
Ashrafioun, L., Bishop, T. M., Conner, K. R., & Pigeon, E. R. (2017). Frequency of prescription opioid misuse and suicidal ideation, planning, and attempts. Journal of Psychiatric Research, 92, 1-7.
Bohnert, A. S. B., Walton, M. A., Cunningham, R. M., Ilgen, M. A., Barry, K., Chermack, S. T., & Blow, F. C. (2018). Overdose and adverse drug event experiences among adult patients in the emergency department. Addictive Behaviors, 86, 66-72.
Brennan Braden, J., Edlund M. J., & Sullivan, M. D. (2017). Suicide deaths with opioid poisoning in the united states: 1999–2014. American Journal of Public Health, 107, 421-426.
Oquendo, M. A., & Volkow, N. D. (2018). Suicide: A silent contributor to opioid-overdose deaths. The New England Journal of Medicine, 378, 1567-1569.