Addiction Policy Forum Blog

7 min read

Suicide might be a root cause of more opioid overdoses than we thought

By Mark Gold, MD on December 12, 2019

An “intentional” suicide attempt by fatal drug overdose refers to an individual seeking to overdose in order to end her life. This may sound straightforward enough. But the issue is much more nuanced, related to how we understand and respond to the opioid overdose epidemic. If all overdoses are considered “accidental” until proven otherwise, we may be missing higher rates of suicide and depression, and different approaches to prevention, identification, and treatment. 

How exactly can coroners and officials who write on death certificates determine whether someone “intentionally” wanted to die by overdose or “unintentionally” died by overdose, without any desire to die at all? The Directors of the National Institute of Mental Health (NIMH) and National Institute on Drug Abuse (NIDA) recently reviewed the literature linking overdose and suicide.1 Up to 30 percent of all accidental overdoses are actually suicides. They observed that, controlling for other conditions, suicidal thoughts are 40-50 percent higher among individuals misusing prescription opioids, and that, “people with a prescription opioid use disorder were also twice as likely to attempt suicide as individuals who did not misuse prescription opioids.”

In the U.S., suicide rates are increasing, overdoses are increasing, and life expectancy is decreasing—“deaths of despair”, they are often called. Between 1999 and 2009, opioid-related suicide rates doubled.2 Opioid-related overdose deaths among Americans and adolescents have also surged. And both opioid-related deaths and suicides have increased to epidemic levels in the United States. Doctors Nora D. Volkow and Maria A. Oquendo3 have written that declining motivation to live can range “from engagement in increasingly risky behaviors despite a lack of conscious suicidal intent to frank suicidal ideation and intent.” Most of what we used to think as leading causes of death have been decreasing. Deaths due to cardiovascular disease, cancer, stroke, and lung disease have all been steadily decreasing since 2000. But deaths from drugs, alcohol, and suicide have been increasing. Things have changed so much and so fast that more U.S. deaths now result from self-harm than even diabetes.4 Suicide is more than twice as common as homicide in the United States. Accidents, which may sometimes be covert suicide, make up the other leading causes of death. The major default manner-of-death assignment for injury cases contain misclassified suicides.5

Yet little attention has been paid to these deaths’ contributions to overdoses, suicide, and addiction.6 In a recent study, nationally recognized research leaders explore the connection between opioid-related overdoses and the spectrum of suicidal motivation.

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7 min read

The fentanyl crisis is only getting worse

By Mark Gold, MD on October 31, 2019

Synthetic opioids like fentanyl accounted for around 3,000 deaths in 2013—by 2018, they accounted for over 30,000.1 Fentanyl is approximately 100 times more potent than morphine, 50 times more potent than heroin. Breathing can stop after use of just two milligrams of fentanyl. That’s about as much as trace amounts of table salt. “Ten years ago,” write the authors of a recent RAND report on the future of fentanyl, “few would have predicted that illicitly manufactured synthetic opioids from overseas would sweep through parts of Appalachia, New England, and the Midwest.” Drug epidemics and outbreaks can be surprising, taking unexpected forms at unpredictable moments in uncharacteristic patterns. But the fentanyl crisis is different. It isn’t just distressingly surprising or one more deadly drug epidemic in a grueling, tragic history of new contagions. Its magnitude, intensity, and sharp variations dwarf previous epidemics with which experts and officials are familiar, and its challenges for public health are novel and, so far, unmanageable. The recent RAND report is a comprehensive overview of the fentanyl crisis’s origins, present status, and, most disturbingly, future.

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8 min read

Substance use disorders take a toll on more than just health

By Mark Gold, MD on October 10, 2019

Many Americans are aware of the United States’ current overdose and addiction epidemic. For patients, families, friends, and loved ones, the tragic health and behavioral effects of substance use disorders (SUDs) are readily recognizable at a level of intimate, granular detail. Among individuals who have used substances, not all have SUDS, but many have spent money on illicit substances. SUD-related discussions frequently focus on survival or addiction, sometimes looking past another elephant in the room: finance. A recent RAND report for the Office of National Drug Control Policy (ONDCP) sheds an important light on how much money we pay for illegal drugs by highlighting Americans’ expenditures on methamphetamine, marijuana, heroin, and cocaine.

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