Suicide Due to Chronic Pain

Here are excerpts from 4 more articles showing that many suicides classified as “overdose” deaths are likely due to chronic pain.

The first article I include below started the “official awareness” that many opioid-overdose deaths may have been due to unbearable pain. Patients are committing suicide when their pain medications are taken away by the over-zealous promotion of anti-opioid policies.

With a powerful and well-known author like the head of NIDA, Dr. Nora Volkow, we can hope that other professionals will take note. 

This was published in the prestigious New England Journal of Medicine:

Suicide: A Silent Contributor to Opioid-Overdose Deaths – Maria A. Oquendo, M.D., Ph.D., and Nora D. Volkow, M.D. – N Engl J Med – Apr 2018

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.

• Accidental overdoses need treatment for addiction.
• Intentional overdoses need treatment for pain and depression.

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.

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.

The distinction between unintentional and volitional deaths may be blurred among people with OUD, whose motivation to live might be eroded by addiction.

Such erosion can have a range of effects, from engagement in increasingly risky behaviors despite a lack of conscious suicidal intent to frank suicidal ideation and intent. This entire spectrum can lead to opioid-overdose deaths, but little attention has been given to its contribution to overdose mortality.

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, ranging from 1% to 85% between 2008 and 2010, with an average of 8%

The CDC recently called for actions such as standardization of definitions and practices and protection against litigation to reduce this variability

the absolute number of deaths from overdoses of undetermined intent has increased significantly as overdose fatalities have more than tripled between 1999 and 2016.

Perhaps of most relevance, 2006–2011 data from the Nationwide Emergency Department Sample that include information on more than 250,000 emergency department visits by adults for opiate overdose show that only

• 54% of the overdoses were classified as “unintentional”:
• 26.5% were deemed intentional, and
• 20.0% were “undetermined.”

The data also document a steady annual increase in opiate-overdose visits to emergency departments. Together, 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.

Educational campaigns to increase public awareness of suicide risk could engage family and friends in interventions to prevent suicidal overdoses by seeking medical assistance. 

Medical assistance for the chronic pain that’s driving so many patients to deliberately overdose seems to be non-existent or unaffordable.

Campaigns to reduce the double stigma associated with suicide and drug addiction might make patients more willing to seek treatment.

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.

Intermingled but different. Our “crisis” is not the monolithic issue the regulators insist on seeing,

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The following article came from the official news site of Psych Congress:

Chronic Pain May Contribute to Suicide – By Linda Carroll – Sept 2018

Nearly one in 10 suicide deaths in the U.S. occurs in people with chronic pain, a new study indicates.

The finding suggests chronic pain may be a risk factor for suicide, the study authors say.

While the study can’t prove that chronic pain contributed to people’s decisions to kill themselves, “we did see that mental health issues, such as depression and anxiety were more common among those with chronic pain,” said lead author Dr. Emiko Petrosky, a medical epidemiologist with the U.S. Centers for Disease Control and Prevention (CDC) in Atlanta.

It’s hard to say whether such “mental health issues” aren’t just another manifestation of chronic pain.

It’s estimated that

• 25 million U.S. adults have some level of daily pain and
• 10.5 million of them have considerable pain every day

“Chronic pain is a huge public health problem. It’s essential that we improve chronic pain management through integrated patient centered management that includes mental health care in addition to medications for these patients.”

The proportion of suicides committed by people suffering from chronic pain increased during the study, rising from 7.4 percent in 2003 to 10.2 percent in 2014. But Petrosky’s team also underscored the fact that the percentage of people battling chronic pain also rose during the same time period.

“Chronic pain is certainly an important risk factor, but we don’t know how important it is compared to other risk factors,” said Wasan, who was not affiliated with the new research. “Also, sincechronic pain is not really coded well at the time of a suicide, this is probably an underestimate of the proportion of people who had chronic pain.

We do know that chronic pain can be a deadly disease.”

Those words are so true, and so rarely understood by people who don’t have to live with it.

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Here’s anpther article about it from the respected journal, Annals of Internal Medicine:

Pain, Opioids, and Suicide Mortality in the United States | Annals of Internal Medicine | American College of Physicians – Mark Ilgen, PhD – Oct 2018

I hope this doesn’t become another reason to deny opioids.

Because chronic pain can lead to suicide, it’s a catch-22:

• Giving sufficient opioids can reduce pain and lessen suicidal thinking, even though it also provides the possible means for suicide.
• Not giving sufficient opioids can result in the patient’s pain becoming intolerable, and then they will become suicidal.

Persons with a chronic pain condition may endure considerable suffering, including poor functioning, depression, and anxiety.

In addition, many studies have linked chronic pain to a higher risk for fatal and nonfatal suicide attempts.

The elevated rates of suicidal behaviors in persons with chronic pain reflect the direct and indirect ways chronic pain relates to suicidal thoughts, plans, and attempts.

The overall prevalence of chronic pain in persons who die by suicide is notable and has increased over time, with more than 10% categorized as having pain in 2014, the most recent year analyzed.

Because Petrosky and colleagues had access only to data collected after death, which often are incomplete, the estimated percentage of the decedents with pain in this study probably underestimates the true prevalence of pain in those who die by suicide.

These findings mirror the broader epidemiology of pain in the United States, in which similar pain conditions and comorbid psychiatric disorders are common, yet the vast majority of persons with co-occurring pain and anxiety or depression do not die by suicide.

suicide decedents with pain seem to be a diverse group with several risk factors for suicide. This argues for a general suicide prevention approach whereby all persons with chronic pain are asked about mental health symptoms as well as recent and lifetime suicidal thoughts and behaviors

Two very different and competing initial hypotheses exist for how opioids may relate to suicide risk in persons with chronic pain.

On one hand, opioids are potentially lethal in higher quantities, and the suicide prevention literature has consistently demonstrated that access to lethal means can increase the risk for suicide.

On the other hand, opioids may reduce suffering in persons with chronic pain, and ongoing efforts to reduce higher-dose opioid prescribing might lead to an increase in suicide among those with pain

Given the current national opioid epidemic, it is important to consider the potential ways opioids might be a link between pain-related suffering and suicide.

Thus, although a substantial number of suicides among those with chronic pain seem to involve opioid use, many suicide decedents with access to opioids—at least as indicated by the presence of opioids in toxicology results—die by another method.

So this rules out the idea that the opioid medication itself is responsible.

This finding is consistent with previous work in U.S. military veterans showing higher suicide rates among those receiving higher opioid dosages; this research also found that the vast majority of suicides involved firearms, even in veterans receiving the highest opioid doses.

the association between higher opioid dosages and a greater risk for suicide may reflect the fact that those with a higher opioid dosage are more likely to have poorly controlled pain.

I’m so pleased that the author understands this when so many people ignore pain entirely and match high opioid doses with overdose/suicide without accounting for this underlying factor.

These results argue for a more nuanced view of the role of opioids in suicide among persons with pain. A minority of persons with pain who receive opioids may be at higher risk for suicide by opioid overdose, whereas others with pain may receive some benefit from opioids and will not become suicidal.

more than two thirds of suicide decedents with a pain condition mentioned their pain, as well as longstanding suffering from this pain, as a direct contributor to the suicidal crisis.

This observation highlights the need to improve pain treatment, not only for the direct effect on pain and functioning but also as a method to raise hope in persons with chronic pain.

…suicide may be a potentially lethal consequence
of suffering in patients with pain.

Suicide prevention involves making effective pain interventions more available.

Yes! This is what I argue as well in Pain Awareness IS Suicide Prevention.

These pain-related interventions need to be supplemented with mental health treatment in persons with pain and depressive and anxiety-related symptoms to foster hope and help address suicidal thoughts and plans.

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And here’s a story in the popular media about the topic from the Daily Mail:

Chronic pain drives millions of Americans to suicide – By Mia De Graaf – Sept 2018

Chronic pain from cancer, arthritis, and other conditions drives millions of people to suicide every year, a new report warns.

a new report by the CDC warns overdoses account for a minority of deaths among people who suffer from chronic pain.

In recent years, the number of chronic pain patients intentionally taking their own lives has soared, with most cases committed using a firearm.

New data compiled by researchers at the Centers for Disease Control and Prevention, published today in the journal Annals of Internal Medicine, hammer home why there is more to it than habitual discomfort.

Looking at just 18 states between 2003 and 2014, lead author Emiko Petrosky and colleagues found 123,181 people had committed suicide. A staggering nine percent of them (10,789) had been battling chronic pain, particularly from things like arthritis, cancer and back pain.

It was a connection that became stronger and stronger over the years.

• In 2003, 7.4 percent of suicide cases were tied to chronic pain.
• By 2014, that figure had risen to 10.2 percent.  

Firearms are the most common cause of death for all suicides in America, but this study shows it is more common for people with pain (53.6 percent) than those without (51 percent). Meanwhile 16.2 percent of pain patients who committed suicide died by overdose.

Writing in an editorial released in tandem with the study, Dr Mark Ilgen, of the department of psychiatry at the University of Michigan, says the findings show a clear need to ‘raise hope in persons with chronic pain’.

‘Suicide prevention involves making effective pain interventions more available,’ he says, but warns that that is, clearly, not enough.

‘These pain-related interventions need to be supplemented with mental health treatment in persons with pain and depressive and anxiety-related symptoms to foster hope and help address suicidal thoughts and plans.