Many Opioid Deaths are Suicides

Suicide Accounts for Higher Percentage Of Opioid Deaths Than Previously Believed – Pain Medicine News – by David Holzman – Sept 2018

In 2016, 42,000 Americans died of an opioid overdose, according to the CDC. In the past, just a tiny fraction of those deaths would have been counted as suicides.

But now, Maria A. Oquendo, MD, PhD, the chair of the Psychiatry Department in the Perelman School of Medicine.and Nora D. Volkow, MD, the director of the National Institute on Drug Abuse,estimated that 20% to 30% of these deaths (8,400-12,600) were likely by suicide. Dr. Oquendo told Pain Medicine News that the rate could be as high as 40% (16,800).

Pain Medicine News editorial advisory board member Lynn R. Webster, MD, believes death by suicide may be even more prevalent among opioid overdoses than Drs. Oquendo and Volkow suggest.  

“If you know significant numbers of deaths are due to intractable, unrelievable pain or mental health disorders, the interventions will be different from interventions based on the belief that doctors are overprescribing opioids.”

The former conditions would dictate treatment by relieving the pain, or treating the mental health disorders, respectively, whereas for the latter, the indication would be a reduction in prescribed opioids.

Suicide and Suicide Notes

The three most common means of death by suicide are

1. firearms,
2. hanging and
3. poisoning, namely, drug intoxication.

Suicide by gunshot or hanging is almost always highly classified, due to its overt nature. When drug overdoses are involved, cause of death is more frequently labeled “accidental” or “undetermined,” said Eric D. Caine, MD, the second author of the PLOS One paper, and chair of psychiatry at the University of Rochester Medical Center, in New York.

The problem faced by medical examiners and coroners determining intent in drug overdoses is lack of information and resources for conducting an investigation.

Undetermined and accidental are default categories, and as such, very susceptible to suicide misclassification, Dr. Rockett said. The resources are lacking that could otherwise enable medical examiners and coroners to comb medical records for predisposing mental health conditions and interview those who knew the decedents well enough to shed light on suicidality.

Dr. Connery emphasized that drug intoxication deaths and suicidal behaviors have been artificially separated—often being treated by different clinical systems.

“There was an assumption that opioid-related overdoses were never intentional,” but rather the result of reckless use, Dr. Connery said. But “substance use disorder and suicidality go together.”

Indeed, because the external and internal situations that drive a substance use disorder (feeling miserable, worthless, and hopeless) are the same ones that drive suicides.

Most drug overdoses are an outcome of suicidal behavior, even if they aren’t outright suicides. When a person injects illicit drugs these days, they usually know they are tempting fate… even if they aren’t specifically trying to kill themselves.

Patients with substance use disorder frequently experience suicidal thoughts, wish for death, and feel like a burden on others, Dr. Connery said. “Many who have survived an overdose will report that they didn’t care at the time if they woke up or not, and some will say, ‘I was hoping I wouldn’t wake up.’”

Between people with major depressive disorder and those with substance use disorder, the latter have a greater capacity for completing death by suicide, “because of frequency and impulsivity,” Dr. Connery said.

For patients with substance use disorder, “suicide prevention has to be part of the comprehensive treatment plan.” Among other things, “moderate to severe pain patients should be screened for suicide risk at evaluation and ongoing,” she said.

It’s ironic that they worry so much about a pain patient’s suicide risk even as they are withholding effective pain relief.

If they screened for pain level (which is why the patient is there in the first place) and treated it appropriately, the suicide risk would evaporate. If they are so concerned about pain patients suicides, why not prescribe them the medicine that can relieve the cause?

I’m disappointed there’s not even a mention of all the pain patients being forced off of opioids, which has become an obvious cause of suicides.

Limitations

The main weakness of the study is that it was inferential, said Dr. Caine, noting that researchers can’t place cameras in coroners’ and medical examiners’ offices.

“Additionally, almost anyone might guess what this study confirmed: When a person hangs himself, coroners and medical examiners are far quicker to call it a suicide than if the means of death involves an overdose of substances, even if those other clues—like a note—are lacking,” Dr. Kertesz said.

given an admittedly tough problem, and limited resources, it is indeed quite likely that we are underestimating how many suicides are happening in the U.S., and we are particularly likely to do that when the means of death involves a toxic poisoning.”

I’m gratified that someone is starting to pay attention to the link between suicide and chronic pain, especially now during both “Pain Awareness Month” and “Suicide Prevention Month”: Pain Awareness IS Suicide Prevention.