Suicide Deaths Are a Major Component of the Opioid Crisis that Must Be Addressed

Directors Dr. Nora Volkow (NIDA) and Dr. Joshua Gordon (NIMH)

September is National Suicide Prevention Awareness Month. In observance, our two institutes, the National Institute on Drug Abuse (NIDA) and National Institute of Mental Health (NIMH), are taking this opportunity to highlight a dimension of the opioid crisis that receives too little attention—the links between opioid use, opioid use disorder (OUD), and suicide.

We’ve heard a lot about the opioid epidemic, and the rising toll it is taking on our communities. In 2017, 47,600 people died from overdoses involving prescription or illicit opioids. But the opioid overdose epidemic is not limited to people with opioid addiction who accidentally take too much of a pain reliever or unknowingly inject a tainted heroin product. Concealed in the alarming number of overdose deaths is a significant number of people who have decided to take their own life.

It can be challenging to discover the true relationship between suicide and drug use. In the absence of a suicide note, it is difficult to assess the intentions of an individual who has died of an overdose, other than circumstantially. Also, the intentions of someone with OUD who overdoses may not always be clear-cut. In a study last year of current and past overdose experiences among patients seeking treatment in a Flint, Michigan emergency department, 39% of those whose worst overdose had involved an opioid or sedative reported wanting to die or not caring about the risks; another 15% reported they were unsure of their intentions.

While we don’t know exactly how many opioid overdoses deaths are actually suicides, some experts estimate that up to 30% of opioid overdoses may fit this description. The connection between opioid overdose and suicide has appeared to increase over time, with one 2017 analysis of National Vital Statistics data showing significant increases in suicides involving opioids among all age groups except teens and young adults between 1999 and 2014; in those aged 55-64, the rate quadrupled.

Research seeking to understand the link between suicide and opioid use suggests the two may be entangled in multiple ways and for many reasons. A 2017 study using national survey data showed that people who misused prescription opioids were 40-60% more likely to have thoughts of suicide, even after controlling for other health and psychiatric conditions. People with a prescription opioid use disorder were also twice as likely to attempt suicide as individuals who did not misuse prescription opioids.  

People with substance use disorders also frequently have other psychiatric disorders—for example, they are twice as likely to have mood and anxiety disorders, which are independently associated with increased suicide risk. The reverse is also true. Half of all individuals with a mental illness will—at some point in their life—have a substance use disorder. Moreover, mental illnesses are also associated with accidental overdoses of medications and illicit drugs.

Pain is another important factor when considering the complex relationships between opioids, overdose (both suicidal and accidental), and mental illnesses. Individuals suffering from chronic pain conditions—the primary reason people are prescribed opioids—may also have comorbid depression or other mental illnesses, and they may be at increased risk of suicide simply because of their pain. Individuals who take higher quantities of prescribed opioids for pain are also at an increased risk of accidental overdose death. With current initiatives to reduce opioid prescribing, many pain patients find themselves either unable to get treatment they need or stigmatized as “addicts” by the healthcare system, compounding their difficulties.

Our Institutes are engaged in research initiatives that address the suicide component of the opioid crisis. NIDA funds research aimed at understanding the complexities of addiction, including co-occurring mental health problems and shared environmental and genetic risk factors for addiction and mental illness. NIMH funds research aimed at understanding the causes of suicide and suicidal ideation and seeks to develop new prevention and treatment interventions specifically targeting suicide.

The opioid crisis and the deaths of despair associated with it demand addressing the larger mental health context of opioid use and misuse. We must fully utilize the effective OUD medications at our disposal in addition to addressing the many risk factors for suicide, particularly co-occurring mental illness and pain, in those who use opioids. This is why the NIH HEAL (Helping to End Addiction Long-termSM) Initiative is so important. The initiative builds upon well-established NIH research to improve prevention and treatment for opioid misuse and addiction. It also aims to enhance pain management by developing effective but safer substitutes for opioids.

As part of this initiative, participating NIH institutes will be funding clinical trials of collaborative care models to treat people with opioid use disorder and co-occurring mental disorders. Collaborative care models, which involve mental health professionals, care managers, and primary care physicians all working together, are already recommended for depression and post-traumatic stress disorder. Recent evidence suggests they could be effective for substance use disorders and for reducing suicide risk. These new grants aim to demonstrate this efficacy definitively and to show how collaborative care can be implemented in community health centers in the areas hardest hit by the twin epidemics of opioid overdose and suicide deaths.


Dr. Nora Volkow, Director

Here I highlight important work being done at NIDA and other news related to the science of drug use and addiction.

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 Suicides and Addiction

Wonderful to have this topic finally reach the surface. "Accidental overdose" is so easy to say, dismissing everyone from asking the tough(er) questions, exhonerating intention. But, "accidental overdose" must be - all too often - a diagnosis of convenience.

We can expect this situation to worsen. As machine learning artificial intelligence makes jobs obsolete and people left to wander with insufficient skills and unclear purpose we can easily predict that an increasing portion of the population will be disillusioned into desperation. Prior technological revolutions have broadly pivoted away from simple, repetitive physical work and toward skilled or intellectual work. But, now our greatest asset is challenged, soon to be surpassed in important ways. We don't have another card to play. Those who have neither the emotional nor intellectual skills to remain ahead of machine capability will grapple with existential angst by drugs - or departure. This is already evident.

 Chronic pain

I think it's disingenuous to act as if the opioids cause the suicide when the truth is that so many people have had their medication tapered forcefully or abandoned by their doctors completely! The unending pain causes the suicide and those last few pills just make it less painful. If you want to decrease suicide start treating the pain! You still mix the prescription with the illegal to make sure we suffer.

 We Need to Find Real Balance in Drug Regulation Policy

Dr Volkow will be aware of some of my publications concerning medically managed opioids. I assert that a preponderance of data published by CDC and in major demographic studies such as Dasgupta et al in NC, conclusively demonstrate that our opioid "epidemic" cannot be caused by doctor prescriptions. Seniors over age 62 are prescribed opioids six times more often than youth under age 19. But overdose mortality from all sources in youth is six times higher than in seniors. Prescribing practice did not create this debacle. We can't get there from here!

Part of the rising trend in suicide is a consequence of patients being denied effective pain management and deserted by their doctors,driven into street drugs or medical collapse. Another part is grounded on deepening social despair, as Dr Barbuto accurately portrays. In both cases, the implied conclusion is that National policy must change in major ways, to redevelop our work force and revitalize communities. More immediately, we must reign in DEA and State authorities, to stop the persecution of doctors out of pain management practice.

Real progress on addiction and suicide won't come cheaply or easily in the face of deeply entrenched special interests that influence policy disproportionately. But recognizing the nuances of these issues is a positive step. I commend Dr Volkow and Dr Gordon for their attempt.

 denial of opioids causes suicides not because we are addicts

I am so tired of reading stories that do not have the facts straight. Addiction of chronic pain patients has been proven to be less than 1%. The medications taken by chronic pain patients is directly aimed to the brain's pain sensors to relieve pain. There is no "high" effect whatsoever. There is a huge difference between prescription and prescribed opioids. Opioids are stolen and sold for $25 a pill on the streets or taken to parties for distribution among young adults. Both are examples of "prescribed" opioid abuse. There are over 50 million people currently living with chronic pain, myself included. We have been stigmatized and shamed just because we want some quality of live. Patient suicides are rising everyday not just by overdose, but in any way they can so the suffering can end. Depression and anxiety are linked to disability caused by chronic pain. I'm 58 and have been taking opioids for 14 years without a single inkling to take my medication for other than it is intended. I have been taking antidepressants since I became disabled because I was so depressed about the pain and illnesses that cause it. I was on Diazepam for over 5 years for chronic muscle spasms and anxiety. In March, the law said I can no longer take it because I am on opioids. Someone has to start noticing us as human beings and not addicts.

 opiods and suicide

Males are more likely to complete. Of psychoactive subs, alcohol is highly associated. Based on psychosocial autopsies I've performed, they are useful in detecting contributing factors.

I know that our local coroner does not have a team to conduct these useful investigations. For me increasing despair and desperation leads to the "threshold of no return".
Very pertinent topic.

 Celebrities committing suicide

NIDA, please correct me if I'm wrong, but I think recreational abuse of addictive drugs such as alcohol and opioids may cumulatively reduce the zest for life which may unfortunately lead to suicide. And that's because artificially stimulating the brain's pleasure, neural circuits can reduce an individual's natural ability to feel good.

Relying on further use of opioids just to feel good and normal, the brain's natural ability becomes further diminished in an unfortunate downward spiral of dependency.

Basically, many who abused recreational drugs in the past gradually lose their zest for life, even the ability to enjoy simple pleasures. It's a hopeless and desperate situation of turmoil. They simply cannot just feel 'normal'. Left unaddressed, these people see no way out and commit suicide.

In fact, over the years we are seeing one celebrity after another take their own life. We conclude it was caused by depression, but then again, they all very often endured drug or alcohol addiction in the past.

I suspect these celebrities, despite the imagery of wonderful lives they portray, also internally experience feelings of desperation and hopelessness derived from past addiction. Basically substance abuse has caught up with them and they feel hopeless.

All so tragic, and what's just as bad is that society mostly covers up the real reasons because of the fear of being stigmatized as a "drug addict". It's a shame because if most people understood the truth, we could save a lot more lives.

 23 years of Pain Mgt - Never been so disheartened by How this is

agree with commenters. Need to separate drug abusers from pain mgt. folks trying to live a quality life. I am 100% disable Vet, broke my back in 1980 my senior year West Point. 5 major spine surgeries, 5 knee surgeries, 4 life saving surgeries after massive PEs, DVTs, IVC filter thrombosis. avascular necrosis of both hips. etc. I started pain mgt w/opioids in 1994 after 20 hrs of spine surgery. They had me on 1500mg/day for 10 years. I was bedridden 3 years and then worked thru tough pain as a very senior leader in Dept of Army. Pain mgt/PT helped me get my career back despite massive dosage. After 10 years I was able to slowly taper on my own. I continued down from 1500mg/day to 420mg/day over 5 years was hugely successful in my career. Then it became the prevailing trend to consider us all addicts. I was forced into withdrawal cutting me by 40% in a month. Then they did it again a year later-CRUEL. I nearly died from IVC filter thrombosis and DVTS both legs and they still wanted to cut my pain mgt. I have never taken a single pill more than prescribed. I am 100% disabled and struggle with the pain I used to manage far better. I am taking 120mg/day and they still say its too much. I work 15hrs a day at home in self built business. I will fight to live til the end. But I am not an addict.