Fewer Opioid Deaths May Be Due to Suicide Than Previously Estimated

Fewer opioid overdose deaths may be due to suicide than has been estimated, according to a study published in JAMA.

Though some studies have suggested that up to a quarter of all opioid overdose deaths are intentional, Mark Olfson, M.D., M.P.H., the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law at Columbia University Vagelos College of Physicians and Surgeons, and colleagues determined that 4% of opioid-related deaths were due to suicide in 2017.

The researchers evaluated death certificates from 2000 to 2017 obtained from the National Vital Statistics System to determine the proportion of deaths that were unintentional, due to suicide, or of undetermined intent.

Between 2000 and 2017, opioid-related deaths per 100,000 increased from 2.20 to 13.21 for unintentional deaths and 0.27 to 0.58 for suicides, according to the study.

“Viewing the threat posed by opioid abuse and suicide as distinct, though sometimes related, conditions could change how people with opioid use disorders and their families understand opioid addictions and how they seek treatment for them,” Olfson said by email. “It is important for patients and their family members to understand that there are effective medication treatments for opioid addiction and different medication and psychological treatments for depression. These are separate conditions, which though they can occur together, respond to different treatments.”

The study shows that the opioid crisis is clearly getting worse, said John Renner, M.D., a member of APA’s Council on Addiction Psychiatry and professor of psychiatry at Boston University. But it is difficult to clearly determine whether an overdose was intentional or unintentional, as the quality of coroner data is often inconsistent, he said.

The authors also pointed this out as one of the study’s potential limitations, adding, “With greater public appreciation of the opioid epidemic since 2010, certifiers may be more likely to consider opioid overdose deaths as unintentional.”

But even if a smaller proportion of overdose-related deaths are intentional than previously estimated, Renner said, that should not impact treatment. “There’s a very high overlap between other psychiatric disorders and substance use,” he said. “I certainly think that, if you are working in an emergency room and treating people who just overdosed, you ought to be asking very carefully whether or not people are suicidal or if they are depressed.”

The line between opioid addiction and suicide is fine, agreed Elie Aoun, M.D., an assistant professor of psychiatry at New York University and vice chair of APA’s Council on Addiction Psychiatry. “We know that opioid use affects mood and anxiety, and increases the feeling of hopelessness,” he said. “So even if the opioid is not taken with the intention of causing death, opioid use causes severe mood symptoms, and a lot of the patients that we treat say that they reach the level of hopelessness that they don’t care if they die as a result of their opioid use.

“It could cause more harm if we’re sending the message that suicide and unintentional opioid overdoses are not related,” he continued. “As much as we would like to separate these things into distinct categories, they’re really intertwined, and one affects the other.”

The study did not have external funding. ■

“Trends in Intentional and Unintentional Opioid Overdose Deaths in the United States, 2000-2017” is posted here.