It’s long been suspected that the nation’s unprecedented drug overdose epidemic and sharply rising suicide rates are linked.
Now health researchers are finding concrete evidence that the two preventable causes of death — which are among the top 10 in the United States — are intrinsically related: People with an opioid addiction are at much higher risk for suicide than the rest of the population; and opioid use was a contributing factor in more than 40% of all suicide and overdose deaths in 2017, according to data from the U.S. Centers for Disease Control and Prevention.
Suicide prevention advocates have been pushing the addiction treatment community to address the substantial overlap by evaluating all patients for suicide risk and employing preventive techniques for those who need it.
In June, that’s slated to happen.
New guidelines recommended by the National Action Alliance for Suicide Prevention will become facilities’ minimum standard of care for patients in both inpatient and outpatient addiction treatment, said Michael Johnson, managing director for the Commission on Accreditation of Rehabilitation Facilities, which oversees opioid treatment programs and other rehabilitation services.
“Right now, there’s no real standards for suicide prevention in addiction treatment programs,” he said. “We want to change that.”
Some drug treatment programs already screen patients for suicide and offer suicide prevention therapies. Soon, all treatment programs will have to meet the standard to maintain their accreditation from the Commission on Accreditation of Rehabilitation Facilities.
According to the National Action Alliance, other health care organizations that have used its suicide prevention approach saw a 60% to 80% reduction in deaths.
Michael Hogan, a behavioral health consultant who has headed mental health agencies in Connecticut, New York and Ohio, said the guidelines have the potential to save thousands of lives. By his estimate, at least 7,000 people in the care of publicly funded behavioral health programs die by suicide each year.
Nationwide, more than 47,000 Americans died by suicide in 2017 and more than 70,000 died from a drug overdose, according to the Centers for Disease Control and Prevention.
“When people feel hopeless and in distress, they may resort to drugs. But they also may resort to suicide,” Johnson said. “The more we can do to create hope for people and help them stay connected to others, the better they’ll do overall. We need to address the root causes.”
In fact, many of the therapeutic techniques used to prevent suicide in people deemed at risk of harming themselves are similar to treatments for people who are addicted to drugs and alcohol, Johnson said.
But with suicide, there’s an additional need to develop a safety plan to help people avoid suicide when they experience powerful urges to end their pain, said Julie Goldstein Grumet, a clinical psychologist who helped develop the new guidelines and directs behavioral health initiatives for the Suicide Prevention Resource Center in Massachusetts.
Safety plans, which have been used for years in some hospital emergency departments, are typically developed in collaboration with a patient’s family, friends and caregivers. In most cases, the plans include both a list of contacts to call when suicidal urges occur and methods of preventing a patient’s access to lethal means, such as locking up guns and giving the key to another person.
Until recently, there was little evidence that safety plans or any other suicide prevention methods worked.
But a study published in September, led by a researcher at Columbia University, showed that using safety plans for people who were discharged from Veterans Health Administration hospital emergency departments after attempting suicide, and following up with those patients through regular phone calls, cut future suicide attempts in half.
The new guidelines for opioid treatment programs will recommend the use of similar safety plans. In addition, treatment providers will be called on to screen incoming patients for suicide risk, using one of several evidence-based methods.
And to catch those who may not have exhibited suicidal tendencies on that particular day, treatment providers will be urged to reevaluate patients as often as possible throughout their course of treatment.
Suicides and drug overdoses, combined, killed Americans at twice the rate in 2017 compared with 2000, and opioids, whether consumed for pain or used illicitly, were a major contributor, according to a statistical analysis published in January by researchers at the University of Michigan.
Using data from the CDC, the researchers found that combined deaths from suicides and unintentional overdoses jumped from about 41,000 in 2000 to nearly 111,000 in 2017.
When accounting for an increase in U.S. population during that time, the researcher found that the two causes of death had risen from roughly 15 per 100,000 people to nearly 34 per 100,000 in 17 years.
Opioids increase depressive symptoms, which can both increase the risk of suicide by any means and lead to intentional and unintentional overdose death, the study found.
In addition, opioid addiction has “a profound influence” on life factors such as social isolation, legal problems and unemployment that are also known to increase the likelihood of suicide, the study concluded.
“We know that if you have a substance use disorder, your risk of suicide is five to six times higher than the general population,” said Brian Ahmedani, a suicide researcher at the Henry Ford Health System in Detroit.
More than 2 million Americans are addicted to opioid painkillers or heroin, and about a fifth of them have received treatment, according to the U.S. Substance Abuse and Mental Health Services Administration.
“It makes sense,” Ahmedani said, “to provide high-intensity suicide care for everyone in this population.
“If we provided perfect suicide care to every person in behavioral health care,” he said, “we’d touch about 30% of all people who die by suicide, and that would be enough to flatline suicide rates.”
But that hasn’t happened for a couple reasons, Hogan said.
“The treatment field has been so under-resourced and so slammed and so focused on its own mission — keeping people from relapsing — that it hasn’t focused on the suicide risk among people in its care.”
Opioids, alcohol and other depressants negatively affect emotional control, which impairs people’s judgement and jeopardizes their safety. About a third of people who die by suicide were intoxicated in some manner at the time of their death, Hogan said.
A 2018 analysis co-authored by National Institute on Drug Abuse Director Nora Volkow showed that between 20% and 30% of opioid overdose deaths counted as accidents are suicides, based on forensic evidence.
Adding those uncounted deaths to the already steeply rising number of people who die by suicide — more than 47,000 in 2017, according to the American Foundation for Suicide Prevention — underscores the need to address as one the entwined public health crises of addiction and suicide, Hogan said.
“If we can reduce opioid addiction, we can reduce suicide,” he said. “But here’s how I look at it: There may not be a lot we can do to reduce suicides in the entire population. The least we can do is try to prevent it for people who are already in our care.”