By Mark Gold, MD
The number of Americans we lose each year to suicide and unintentional overdose has increased more than 250% since 2000. These problems continue to worsen and have become the most pressing public health issues our nation is currently grappling with. In 2017, over 40% of suicide and overdose deaths were known to have involved opioids, and rates are likely higher due to unrecorded opioid involvement. The connection between opioids and unintentional overdose is clear, but the distinct relationship between opioids and suicide risk is lesser known and has only recently been recognized.
In this review, Amy Bohnert, Ph.D., and Mark Ilgen, Ph.D., apply the commonality of opioid use between these two problems as a crucial framework for examining what is currently known about the links between them.
What is driving the increase in intentional and unintentional opioid overdose?
There are a number of drivers of opioid use, but certain pathways have been theorized to increase vulnerability to suicide and unintentional overdose: pain, increased prescribing and availability of opioids, and socioeconomic stress.
Pain, because of its impact on neurocircuitry related to reward, makes a person more vulnerable to suicide and potentially for riskier opioid use.
There are two main theories concerning the role of opioid use in escalating rates of suicide and overdose. The first focuses on the increased supply of opioids, prompted in the early 2000s by concerns about the undertreatment of pain, which led to the development of new clinical guidelines and a reclassification of pain as the “fifth vital sign.” These changes coincided with a 600% increase in opioid dosage per person per year between 1997 and 2007. These higher prescribed dosages are directly correlated to increased rates of suicide attempts and fatal and nonfatal overdoses.1,2,3,4 Rising prescription prescribing rates, in addition to the increasing availability of heroin and other synthetic opioids, means that opioids are more widely available than ever before. However, it is not clear what amount of this increased supply was a reaction to demand.
The second theory addresses intentional and unintentional overdoses as “Deaths of Despair, ”5,6 and argues that the public health crisis reflects the distress of working-class individuals in the face of rising economic insecurity. The use of opioids to cope with emotional and physical stress further aggravates feelings of depression and pain - increasing one’s risk for suicide and overdose as well as overall demand for opioids.
Shared Prevention and Harm Reduction Strategies
An in-depth assessment of other risk factors, suicidal ideation, and past attempts and overdoses for high-risk patients.
Preventing suicide or overdose among those at risk
Cognitive behavioral therapy for suicide risk;
Motivational interviewing for overdose risk 7,8;
Treatment for mental health conditions, when present;
*Counseling and pharmacotherapy may reduce the risk of both overdose and suicide
Improved access to medication-assisted treatment;
Distributing naloxone and educating about overdose;
Integrating mental and behavioral health treatment into primary care settings.
Opportunities for Further Research
Although tapering can help a patient reduce levels of prescription opioid usage, there are fears that opioid tapering can lead to a patient using heroin as a substitute, or experience increased suicidality as pain increases again. Therefore, opioid tapering should be managed carefully, with adequate pain management alternatives and a transition to medication-assisted treatment if necessary.
Risk scores are only moderately successful at identifying the risk of opioids misuse. To improve this, we may consider evaluating a person’s opioid misuse and an indicator not just of overdose risk, but of suicidality.
Despite clinical, federal, and state policy efforts, overdose and suicide to be an overwhelming issue in the United States. We may not have adequately addressed the socioeconomic factors that lead to overdose and suicide, and therefore prevention efforts have been insufficient.
Rates of suicide and unintentional overdose have risen significantly in the United States over the past few decades, and opioid use has been a key driving factor. Interventions that address shared causes and risk factors have the potential to help address both problems and lower the incidence of suicide and unintentional overdose.
Bohnert, A. S., & Ilgen, M. A. (2019). Understanding Links among Opioid use, Overdose, and Suicide. New England Journal of Medicine, 380(1), 71-79.
Ilgen MA, Bohnert AS, Ganoczy D, Bair MJ, McCarthy JF, Blow FC. Opioid dose and risk of suicide. Pain 2016;157: 1079-84.
Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305:1315-21.
Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85-92.
Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. ArchInternMed2011; 171:686-91.
Case A, Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci U S A 2015;112: 15078-83.
Case A, Deaton A. Mortality and morbidity in the 21st century. Brookings Pap Econ Act 2017; Spring 2017:397-476.
Bohnert AS, Bonar EE, Cunningham R, et al. A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose. Drug Alcohol Depend 2016;163: 40-7.
Coffin PO, Santos GM, Matheson T, et al. Behavioral intervention to reduce opioid overdose among high-risk persons with opioid use disorder: a pilot randomized controlled trial. PLoS One 2017; 12(10):e0183354.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.