Chronic Pain Among Suicide Decedents

Chronic Pain Among Suicide Decedents, 2003 to 2014 | Annals of Internal Medicine | American College of Physicians – Sept 2018

The CDC finally looks at suicide and chronic pain:

“increases in opioid availability are not associated with greater suicide risk from opioid overdose among patients with chronic pain.”

During 2003 to 2014, the NVDRS identified 123,181 suicide decedents aged 10 years or older, 10,789 (8.8%) of whom had evidence of chronic pain. The percentage of decedents with chronic pain increased from 7.4% in 2003 to 10.2% in 2014, but the percentage who died by opioid overdose remained low overall (<2.0%).  

Table 1 presents 7 pain categories and the 3 most common conditions within each category among suicide decedents with chronic pain. (For a full list of conditions and categories, see the  Appendix and Appendix Tables 2 to 10.)

Table 1. Pain Categories and the 3 Most Common Medical Conditions per Category in 18 States—NVDRS, 2003–2014 (n = 10 789)*

The most common categories were spine pain (24.4%) and musculoskeletal pain (20.8%).

The most common conditions were back pain (22.6%), cancer (12.5%), and arthritis (7.9%).

• (54.4%) of decedents with chronic pain had 1 medical condition,
• 15.7% had 2 conditions, and
• 5.7% had 3 or more conditions;
• the remaining decedents (24.2%) did not have a medical condition noted but had a qualifying keyword in the narrative.

Appendix Table 2. Medical Conditions and Pain by Anatomical Location or Organ System in Suicide Decedents With Chronic Pain Aged ≥10 Years—NVDRS, 18 States, 2003–2014 (n = 10 789)* 

(Click image below to see table in a new window where it can be enlarged)

Table 2. Characteristics of Suicide Decedents in 18 States—NVDRS, 2003–2014 (n = 123 181)*

Discussion

We found that nearly 9% of suicide decedents in 18 states from 2003 to 2014 had documentation of chronic pain in their incident records and that the percentage of decedents with chronic pain increased during the study period.

Our results highlight the importance of pain in quality of life and premature death, and contribute to the growing body of evidence indicating that chronic pain might be an important risk factor for suicide.

So it’s not far-fetched to assume that more pain == more suicide.

We identified a wide variety of medical conditions and pain types among decedents, with back pain, cancer, and arthritis being the most common. Many chronic pain conditions have been associated with suicidality, but the strength of association might differ by the specific pain condition.

We did not stratify by medical condition or pain type when describing the characteristics of decedents, but future research might use the NVDRS to learn more about the pain conditions most strongly associated with suicide.

Establishing the causal role of pain in suicide was beyond our study’s scope. However, our results were consistent with the known epidemiology of chronic pain in terms of temporal trends, age, and sex.

Other factors known to contribute to suicide risk, including interpersonal problems and life stressors, were less frequent among decedents with chronic pain, which might indicate that chronic pain was the dominant stressor in this group.

Also, although we cannot draw definitive conclusions regarding the proportion of suicides directly attributable to chronic pain, our narrative review of suicide notes suggests that the proportion was not trivial.

The proportion of suicide decedents with chronic pain increased during the study period.

Chronic pain has increased in the general population by a similar magnitude, which may partially explain this finding.

Our aging population will only increase the numbers of people who suffer from chronic pain as the body slowly deteriorates over time.

In general, suicide rates are higher among males and peak in middle age. However, suicide rates among decedents with chronic pain increased by age group and remained high among older persons.

Health problems late in life are particularly associated with elevated suicide risk , and the prevalence of chronic pain, especially severe chronic pain, increases with age.

Overall, we found considerably more suicides among males than females, regardless of chronic pain status, in agreement with the suicide literature.

However, the difference was smaller among decedents with chronic pain, consistent with reports that chronic pain is more common in females.

Although opioid prescribing to treat chronic pain has increased in recent years, we found that the percentage of decedents with chronic pain who died by opioid overdose did not change over time. This finding suggests that increases in opioid availability are not associated with greater suicide risk from opioid overdose among patients with chronic pain.

Mental health disorders, particularly depression, were prevalent among decedents with chronic pain, consistent with previous findings.

Chronic pain and depression have complex and bidirectional associations:

Depression is a risk factor for chronic pain, and

chronic pain, in turn, is a risk factor for depression.

Disentangling this complexity was not possible in our analysis.

However, providers should be alert to and possibly screen for depression and suicidal behaviors among patients with chronic pain, especially older patients.

Indeed, a history of suicidal thoughts, plans, and attempts and disclosure of suicidal intent were more common among decedents with chronic pain than those without it, indicating that opportunities for intervention may have been available.

A recent study suggests that among patients with chronic pain, a belief in a medical cure for their pain may act as a protective factor against suicidal ideation.

This finding underscores the importance of access to quality, comprehensive pain care and adherence to best practices to improve both pain management and patient safety

Integrated pain management and coordination of primary care, mental health care, and specialist services are essential for these patients. Other guidelines recommend behavioral health consultation for any patient with a history of suicide attempt or psychiatric disorder and advise against initiating opioid therapy during acute psychiatric instability or uncontrolled suicide risk

In addition, the CDC’s suicide prevention technical package describes several evidence-based prevention strategies relevant to patients with chronic pain:

• strengthening economic supports (such as disability benefit programs),
• strengthening access to and delivery of suicide care (such as mental health insurance coverage), and
• creating protective environments (such as reducing access to lethal means)

More than half of all suicide decedents, with and without chronic pain, died by firearm, whereas approximately 16% of those with chronic pain died by opioid overdose

This analysis had limitations.

First, data were obtained from 18 states and are not nationally representative, and the states included in the study varied over time.

Second, our results probably underrepresent the true percentage of suicide decedents who had chronic pain, given the nature of the data and how they were captured. The reliability and validity of the medical diagnoses endorsed in the investigative reports also are unknown. Historically, patient reports and self-reported survey data have been the primary sources for pain estimates.

Third, our case selection method led to relatively few false-positive results in our narrative review of selected cases, but a small percentage may have been misclassified, especially if pain was not a prominent issue reported by informants who knew the decedent.

Fourth, we did not have information to assess pain characteristics, such as intensity and duration, or to determine medical treatment, and we could not distinguish prescription from illicit opioids.

Finally, we could not assess other factors commonly associated with chronic pain that affect quality of life, such as disability, sleep disturbance, and in the case of terminal illness, the mental and physical effects of coping with end-of-life concerns

Continued surveillance and research are needed to better understand the burden of chronic pain in the United States.