NEJM Article Highlights Links Between Opioid Use and Suicide
The combined number of deaths among Americans from suicide and unintentional overdose increased from 41,364 in 2000 to 110,749 in 2017 and has exceeded the number of deaths from diabetes since 2010. In all, more than 40% of suicide and overdose deaths in 2017 were known to involve opioids, with many more likely to have had unrecorded opioid involvement. This review describes what is known about the links between suicide and overdoses, with a focus on pathways through opioid use, issues of intent, risk factors, prevention strategies, and unresolved issues. Many factors promote the initiation and persistence of opioid use, but several specific pathways toward vulnerability to overdose and suicide are highlighted by the authors, including:
- Pain and risk of suicide and overdose – Pain causes alterations in the neurocircuitry related to reward, which result in vulnerability to suicide and potentially to riskier use of opioids.
- Medical system drivers of opioid prescribing – Beginning in the early 2000s, opioids were increasingly used to treat chronic pain.
- Large-scale supply and demand – One theory traces the causes to increased demand for opioids (i.e., due to declining economy of the working class); the other emphasizes the role of an increased availability of opioids as the underlying cause of increased non-medical opioid use and disorders.
In addition, research has identified several key factors, beyond opioid use, that are related to both suicide and overdose, such as several mental health conditions (i.e., depression, PTSD), and the use of other medications and drugs in combination with opioids.
Opioid use continues to play a critical role in fueling the rates of suicide and unintentional overdose. Interventions that address shared causes and risk factors, such as programs to improve the quality of pain care, expanding access to psychotherapy, and increasing access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems.
As reflected in this review, VA is working on several fronts to combat the opioid crisis and to enhance suicide prevention. For example, VA researchers developed a risk score for both suicide and overdose together that has been implemented nationally. Further, in 2013, VA launched the Opioid Safety Initiative (OSI) – the first of several system-wide initiatives to address opioid overuse. By mid-2016 compared with mid-2012, the number of Veterans dispensed an opioid each quarter had decreased by 172,000, or about 25%. The OSI also prioritized reductions in opioid and benzodiazepine co-prescribing and other non-recommended opioid prescribing practices. VA is a leader in research on this topic, and much of the research cited in this review was made possible by the unique resource that is the VA Suicide Data Repository, which merges data from multiple federal agencies. As another part of VA's efforts, HSR&D researchers conduct numerous studies on both opioids and suicide.
Drs. Bohnert and Ilgen are part of HSR&D's Center for Clinical Management Research, Ann Arbor, MI.
Bohnert A and Ilgen M. Understanding Links among Opioid Use, Overdose, and Suicide. The New England Journal of Medicine. Review Article. January 3, 2019;380(1):71-79.