Depression, Chronic Pain, and Suicide by Overdose: On the Edge – Jun 2011 – free full text PubMed article
Comorbid conditions that pose risks for suicide, especially depression, are prevalent in people living with chronic pain. The true numbers of failed attempts and successful suicides are unknown and may never be determined. Yet risk factors for suicidal ideation are so high in this population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain.
I believe this is a much bigger factor than most people realize. It’s due to a skewed reporting system, which labels any death involving opioids as an “opioid overdose”, no matter what other drugs or factors were involved.
People are mistakenly campaigning against this method of dying, rather than the cause, which is chronic pain.
The purpose of this manuscript is to highlight to clinicians the important association between chronic pain and intentional self-harm. Contemporary understanding of the epidemiology of depression and suicide and the relationship to chronic pain will be reviewed.
The growing concern regarding opioid addiction and fatal poisonings involving opioids has obscured a potentially equally clinically relevant problem of intentional self-harm by overdose.
Pain and Suicide
For many individuals, committing suicide is a way out of a situation or problem that is causing extreme suffering
In examining the various risk factors for suicide, it is apparent that many of these factors can be associated with living in chronic pain. As noted, many pain patients experience concomitant depression and some have histories of alcohol and substance abuse. These patients experience hopelessness and isolation due to their pain, and they endure many losses, including their work and family roles.
patients with chronic pain tend to resist seeking psychiatric or psychological care for fear their pain symptoms will be minimized or considered reflective of an underlying mental disorder. Studies have revealed high rates of suicidal ideation and suicide attempts in patients suffering from chronic pain
50% of chronic pain patients had serious thoughts of committing suicide due to their pain disorder
specific pain-related risk factors, such as pain severity and severe comorbidity, including depression, accounted for the heightened rates of suicidal behavior in chronic pain patients.
A systematic review of this literature by Tang and Crane revealed that risk of successful suicide was doubled in chronic pain patients relative to non-pain controls.
Pain-specific risk factors included location (low-back and widespread pain) and type of pain (e.g., migraine with aura conferred higher risk than migraine without aura, and chronic abdominal pain conferred higher risk than neuropathic type pain); high pain intensity; long pain duration; and presence of co-occurring insomnia.
Screened patients with moderate-to-high levels of depression with or without suicidal ideation should be referred to a behavioral health specialist for co-treatment.
Concern is growing regarding fatal prescription opioid overdose in patients with chronic pain. The exact genesis of these overdoses is unclear but may include accidental overdose in cases of patients attempting to relieve suffering from poorly controlled pain or to induce sleep. Increasing literature shows that a subset of pain patients experience suicidal ideation.
When treating this patient population, the standard of care should include the routine screening of depression and risk assessment of suicide potential.
A search of PubMed yielded several other studies about chronic pain and suicide:
Chronic pain disorders can exert major negative effects on virtually every aspect of an individual’s life. It is not surprising then that many chronic pain sufferers find themselves at a point of emotional fragility where they experience thoughts of ending their life.
Suicidal behavior encompasses a spectrum of experience, from “life weariness” or passive suicidal ideation, to more active suicidal intent and suicide completion. A range of risk factors for suicidal behavior in the general population have been identified, and these apply equally to the chronic pain population: a family history of mental illness, past history of suicide attempts, and the presence of comorbid depression.
With regard specifically to chronic pain patients, elevated suicide risk is also associated with severe or recurrent headache, ambiguous diagnoses (psychogenic pain, abdominal pain), and medicolegal issues related to the pain. A number of suggestions for clinicians managing chronic pain patients with regards to managing suicide risk are given
Chronic pain has been recognized as an important risk factor for suicide, but the identification of relevant predictors within the chronic pain population is at a preliminary stage of research. In a review of suicidality in chronic pain, Tang and Crane (2006) concluded that there is consistent evidence across studies that both depression and longer pain duration increase the likelihood of suicidal ideation,
both self-perceived burden and distress in interpersonal relationships contributed significantly
Of the other variables, only pain duration and depression were retained as significant predictors
It is noteworthy that pain catastrophizing, which has been strongly associated with suicidal ideation in previous research (Edwards et al., 2006), was a significant predictor only until the interpersonal variables were added in the final step
Conceptually it points to the importance and, perhaps, centrality of interpersonal aspects of suicidal thinking. We conclude therefore, that the interpersonal theory may have merit in explaining the elevated rates of suicidal ideation that is evident among individuals with chronic pain.
BACKGROUND: This paper reviews and integrates the growing literature concerning the prevalence of and risk factors for suicidality in chronic pain
RESULTS: Relative to controls, risk of death by suicide appeared to be at least doubled in chronic pain patients. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Eight risk factors for suicidality in chronic pain were identified, including the type, intensity and duration of pain and sleep-onset insomnia co-occurring with pain, which appeared to be pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and problem-solving deficits were highlighted as psychological processes relevant to the understanding of suicidality in chronic pain.
CONCLUSIONS: Programmatic research is urgently required to investigate the role of both general and pain-specific risk factors for suicidality, to examine how the psychological processes mentioned above mediate or exacerbate suicidality, and to develop enhanced interventions for pain patients at risk.
There is a clear relationship between suicide risk and chronic pain conditions. However, the exact nature of this link has been poorly understood, with risk attribution often limited to comorbid depression.
Perceived burdensomeness has already been confirmed as a risk factor for suicidal ideation (SI) and suicide attempt in the general population. Self-perceived burden, studied among medically and terminally ill medical populations, has begun to receive a great deal of attention as a suicide risk factor.
However, this risk has not been considered in an outpatient chronic pain population, a group likely to experience perceived burdensomeness as a particular problem.
Guidelines recommend routine suicide risk screening in medical settings, but many questionnaires are time-consuming and do not allow for the assessment of the presence of newly identified risk constructs, such as perceived burdensomeness.
This retrospective study examined the relationship between depression, perceived burdensomeness, and SI in a patient sample seeking behavioral treatment for chronic pain management.
A logistic regression model was developed, with preliminary results indicating perceived burdensomeness was the sole predictor of SI, even in the presence of other well-established risk factors such as age, gender, depressive symptoms, and pain severity. Findings highlight the potential utility of a single-item screening question in routine clinical care as an incrementally superior predictor of SI in a chronic pain population.
Suicidal ideation, plans, and attempts in chronic pain patients: factors associated with increased risk.
This study describes suicidal behavior in a cross-sectional sample of chronic pain patients and evaluates factors associated with increased risk for suicidal ideation.
One hundred-fifty-three adults with nonmalignant pain (42% back pain) who were consecutively referred to a tertiary care pain center completed a Structured Clinical Interview for Suicide History, the McGill Pain Questionnaire, and the Beck Depression Inventory.
Nineteen-percent reported current passive suicidal ideation (PSI),
13% had active thoughts of committing suicide (ASI), 5% had a current suicide plan, and 5% reported a previous suicide attempt.
Drug overdose was the most commonly reported plan and method of attempt (75%). Thirteen-percent reported a family history of suicide attempt/completion.
Pain-specific and traditional suicide risk factors were evaluated as predictors of current PSI and ASI. Logistic regression analyses revealed that a family history of suicide attempts/completions was associated with a 7.5 fold increase in risk of PSI (P=0.001) and a 6.6 fold increase in ASI (P=0.003), after adjusting for significant covariates.
Having abdominal pain was associated with an adjusted 5.5 fold increase in PSI (P=0.05) and a 4.2 fold increase in ASI (P=0.10).
Neuropathic pain significantly reduced risk for both PSI (P=0.002) and ASI (P=0.01).
Demographics, pain severity, and depression severity were not associated with suicidal ideation in multivariate analyses. These findings highlight the need for routine evaluation and monitoring of suicidal behavior in chronic pain, especially for patients with family histories of suicide, those taking potentially lethal medications, and patients with abdominal pain.