The current opioid epidemic in the United States has been universally recognized as one of the most important public health issues to date. This crisis has cost nearly $80 billion in lost productivity, treatment (including emergency, medical, psychiatric, and addiction-specific care), and criminal justice involvement.1 Opioid overdoses have increased by 200% since 2000, with more than 33,000 individuals dying from opioid overdoses in 2015 alone.2,3
Because of the surge in opioid overdose–related mortality, resources have been devoted to the widespread dissemination of the mu-opioid receptor antagonist naloxone, which is deemed a “rescue” medication administered by emergency departments, health professionals, the lay public, and/or first responders.4 Naloxone use has been successful in saving lives. However, it has not seemed to reduce recidivism, and overdose prevalence continues to increase.5,6 It is best viewed as an intervention analogous to CPR or cardioversion in acute cardiovascular compromise. CPR and cardioversion provide acute rescue and are lifesaving – but do not contribute to the diagnosis and understanding of the chronic, underlying (cardiovascular) pathology that led to the acute event in the first place. Similarly, while naloxone is an essential rescue medication, it is not a treatment for the opioid addiction or the frequently occurring psychiatric comorbidities. In addition, naloxone rescue does not assist with diagnosis or help the physician understand why the opioid overdose occurred. Still, naloxone remains important.
Currently, overdoses are considered accidental in origin until proved otherwise, and that assumption has become an acceptable hypothesis for the many parties involved: This hypothesis permits the patient to receive the much-needed overdose treatment, the physicians to discharge the patient from the emergency department after resuscitation and medical stabilization, the hospital to collect reimbursement, the pharmaceutical companies to continue to raise prices – and the health system to ignore recidivism and/or long-term outcomes.
However, while well accepted, the accidental overdose hypothesis might not tell the entire story. A recent, competing etiological hypothesis is that many opioid overdoses may, in fact, be misdiagnosed suicide attempts.7 National suicide prevalence has been increasing since 1999, and both all-cause mortality generally and suicides specifically have been increasing in white, male, and middle-aged patients, which encompass the same demographic groups affected by the opioid epidemic.8,9
Also, more than 50% of patients with opioid use disorder have histories of major depressive disorder,which, when untreated, may further drive suicidal thoughts and behavior.10,11 Maria A. Oquendo, MD , PHD, immediate past president of the American Psychiatric Association, wrote in a guest post on the blog of Nora D. Volkow, MD , director of the National Institute on Drug Abuse, about the strong link between opioid use disorders and suicidal thoughts and behavior Furthermore, a 2004 literature review on substance use disorders and suicide found that individuals with opioid use disorders had a 13 times greater risk of completed suicide, compared with the general population.12
A recent study of nearly 5 million veterans enrolled in the Veterans Health Administration demonstrated that, even when adjusted for age and comorbid psychiatric diagnoses, opioid use disorder was associated with an increased risk for suicide; particularly striking was that this risk was doubled in women.13
A survey of 40,000 subjects from the 2014 National Survey on Drug Use and Health demonstrated that prescription opioid misuse was associated with an increased risk of suicidal ideation, and weekly misuse was associated with increased suicide planning and attempts.
The data regarding the prevalence of suicidal ideation in patients who have overdosed are limited, although recent evidence from the National Vital Statistics System on adolescent (aged 15-19 years) drug overdose is concerning, with 772 drug overdoses occurring in this age demographic in 2015 alone. Opioids were involved in the vast majority of fatal drug overdoses among this group, and the prevalence of death from opioid overdoses increased during 1999-2007 (0.8/100,000 to 2.7/100,000), stabilized during 2007-2011, declined during 2012-2014 (down to 2.0/100,000) then increased in 2015 (up to 2.4/100,000). While 80.4% of all drug overdoses in this group (including opioids) were considered unintentional, 13.5% were most likely completed suicides.14
These results suggest that, at the very least, some proportion of opioid overdoses are suicide attempts, and the actual prevalence may be much larger. All of this is difficult to discern as these data come from an epidemiological survey with data input as International Classification of Diseases, 10th revision, codes. Thus, the real-life and real-time quality of the psychiatric and postmortem evaluation that led to the determination of a suicide attempt is unknown. More explicitly, because a thorough evaluation and collateral history may have been lacking, this study may have underestimated the prevalence of overdoses that were actual suicide attempts.
Lessons for physicians
Given the epidemiological evidence linking suicidal thoughts and behavior with opioid use disorders, the frequency of overdoses, demographic factors, and recidivism with naloxone rescue, we should be very concerned that many overdoses are unrecognized suicide attempts. Many physicians can recount giving naloxone to a patient – reversing his or her overdose and simultaneously saving his or her life – only to be confronted with anger and combativeness on the part of the patient. When this response occurs, many physicians may attribute the behavioral dysregulation to the patient’s lack of experience with or tolerance to the drug (especially among naive users) or may disregard the emotional response altogether. The danger in physicians’ reacting like this to such behavior is that substantial ambiguity regarding the patient’s motives still remains: Did the patient intentionally use intravenously thinking he or she would die? Was the patient ambivalent about death? Did the patient wish he or she would die – or not wake up? Or was the patient just was playing a version of “Russian roulette” with needles and lethal quantities of opioids?
When considering logical next steps after naloxone reversal to ensure appropriate diagnosis of and treatment for the patient, a psychiatric consultation and thorough evaluation may be indispensable. This is particularly important given that those who attempt suicide or have active suicidal ideation often are evasive about their behavior and current state of mind.15 Thus, these individuals may be unwilling to disclose active suicidal ideation, intent, and/or plans when interviewed. A psychiatrist, however, has the skill set to evaluate risk and protective factors, assess for other psychiatric comorbidities carefully, and make recommendations for safe disposition and comprehensive treatment. Just as a comprehensive cardiovascular evaluation, formulation of a differential diagnosis, and treatment of chronic cardiovascular disease is the standard of care after a cardiac emergency intervention, we suggest quite similar practice standards for an opioid overdose intervention.
Clearly, better data are needed. We recommend high-quality, prospective studies examining the overall prevalence of suicidal ideation with intent and plan in patients who overdose on opioids. These studies should include thorough psychiatric evaluations performed by experts, using evidence-based scales for suicide, substance use disorders, and other psychiatric comorbidities. Research of this nature should make significant strides toward creating standards of care in the management of patients presenting with opioid overdoses that allow for appropriate assessment, disposition, treatment, and, ultimately, sustained recovery and wellness.
Dr. Srivastava is a fourth-year psychiatry resident at Washington University in St. Louis. Dr. Gold is the 17th Distinguished Alumni Professor at the University of Florida, Gainesville, and professor of psychiatry (adjunct) at Washington University. He also serves as chairman of the scientific advisory boards for RiverMend Health.
7. Nora’s Blog. 2017 Apr 20. https://www.drugabuse.gov/about-nida/noras-blog/2017/04/opioid-use-disorders-suicide-hidden-tragedy-guest-blog