Association Between Opioid Prescribing and Suicide Risk in the United States

Psychiatry Online
Jenna L. McCauley, Ph.D., Kathleen T. Brady, M.D., Ph.D.
Olfson and colleagues, reporting in this issue (1), leveraged two robust national administrative data sets spanning 2009–2017 to examine associations between regional changes in key opioid prescribing indicators and regional total suicide deaths, as well as suicide deaths involving opioids. Thoughtful attention was given to the potential for sex and age differences. The study findings largely supported the authors’ hypothesis that the regions experiencing the greatest declines in the percentage of people filling opioid prescriptions (as well as declines in other indicators of higher-risk opioid prescribing) would also exhibit the greatest declines in total suicide deaths, as well as suicide deaths specifically involving opioids.

Data from the Centers for Disease Control and Prevention (2) demonstrate that suicides significantly increased in 44 of 50 states between 1999 and 2016, although rates of increase were heterogeneous, depending on location and the demographic of focus. Concurrently, age-adjusted rates of U.S. drug-involved overdose deaths grew staggeringly from 6.1 per 100,000 to 21.6 per 100,000 (3). Although there has been no shortage of data regarding increases in the prevalence of opioid-involved overdose, close examination of opioid-related overdose deaths in direct association with suicide is less common, with the literature tending to connect these dual public health epidemics via shared risk pathways, such as depression and opioid use disorder (4–6).

To this end, Olfson and colleagues previously (7) evaluated trends in U.S. drug overdose deaths (2000–2017) involving opioids that were certified as unintentional, suicide, or of undetermined intent. The authors concluded that “while the public health crises of opioid overdose deaths and suicide do not appear closely linked, it is nevertheless possible that the national increase in suicides may be partly related to increasing opioid overdose deaths.” The examination of trends in deaths in all three categories is important to data interpretation because determining intent in overdose fatalities is fraught with challenges, as suicide notes are found in less than one-third of overdose deaths (8). Data from the Nationwide Emergency Department Sample 2006–2011 show that 54% of opioid overdoses were classified as unintentional, 26.5% as intentional, and 20.0% as undetermined (9). There is also evidence that intentionality of overdose may be dimensional rather than categorical, and retrospective reports suggest that sometimes intentionality of an overdose cannot be determined (10). Although the percentage of opioid-related deaths that were certified as suicides declined from 9% to 4% over this time frame, the overall rate of opioid-related suicides increased, with overdose deaths attributable to heroin and fentanyl being the most likely contributors to the increases in overall rates of opioid-related intentional and unintentional deaths.

The present study is an innovative extension of this previous work that examines potential direct links between opioid-involved overdose and suicide by leveraging the notable declines in licit opioid prescriptions resulting from numerous public policies enacted across the United States with the intent of promoting more conservative opioid prescribing practices. The authors astutely frame reductions in availability of prescribed opioids as a public health approach to reducing access to lethal means of suicide. Interventions to reduce access to lethal means have been identified as an evidence-based suicide prevention strategy (11).

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