Complex Connections: Pain, Opioid Use, Suicide, and Opioid Use Disorder




Early this month, the New England Journal of Medicine published a review article about this topic. This article, titled, “Understanding Links among Opioid Use, Overdose, and Suicide,” summarized what we know so far about the twin epidemics of suicide and opioid use disorder. [1]

According to the authors, as unintentional opioid overdoses have risen over the past few decades, so have suicide rates, with both more than doubling from 2000 to 2017. We know that opioid use increases risk of unintentional overdose, but it’s been found that opioid use also increases the risk of suicide. People with opioid use disorders are more likely to commit suicide than people with other types of substance use disorders.

Why is this?

The article points out some specific pathways that cause vulnerability to overdose and suicide.

Pain causes changes in the brain that alters its reward system. We know patients with chronic pain are at increased risk for suicide, as well as riskier use of opioids. When opioids became more available at the turn of the century, due to efforts to treat pain more adequately, the average dose per capita increased seven-fold between 1997 and 2007. This availability increased the numbers of people who developed opioid use disorder, which is linked to both unintentional overdose and suicide. Higher doses of prescribed opioids are associated with higher risk for both unintentional overdose and suicide.

This article explained the two primary theories about the connection between increasing rates of both suicide and opioid overdose deaths.

The first theory says that both types of deaths are “deaths of despair,” meaning they occur in people whose general economic conditions are falling. Due to lack of opportunities, social isolation, legal problems and/or economic inequalities, people feel desperate, and look for ways to cope. Opioids dull emotional pain as well as physical pain, but according to this theory, also cause worse depression. This increases suicide risk and overdose risk. This theory is called the demand-focused hypothesis.

Or it could be the other way around, as the second theory explains: increased use of opioids causes decline in social function and increased risk of opioid use disorder, which may increase depression. This is called the supply-focused hypothesis. Studies that show increased suicide risk with higher doses of prescribed opioids would tend to support this hypothesis

To tell the difference, we need quality longitudinal studies to show which occurs first. We don’t have such studies, and we need them. The authors say it’s important to know which theory is more accurate, since public policy approaches to fix the problems would be different if one theory is more correct than the other.

Of course, sometimes we don’t know if a death in unintentional or suicide. Sometimes the people involved don’t even know. I’ve talked to many patients with opioid overdose history. When I’ve asked if it was a suicide attempt, they answer, “I don’t know. I just wanted to feel better. If I died, so be it.” How do we classify such an event?

For sure, opioid use disorder brings despair. Some of my patients tell me that they want to live, but they also want their painful struggle to stop. Since death would be one route of release, it becomes a more acceptable option. Hearing this magnifies the importance of getting patients into treatment.

Or maybe the person alters their description of the event, after they survived. If they admit to suicidal intent, they might fear an involuntary commitment to a psychiatric facility, which usually means enforced opioid withdrawal (at least in my area…in some states, psychiatric facilities do provide MAT), so they claim the incident was accidental.

There are shared risk factors for both types of deaths. Both suicide and overdose deaths are more than twice as likely to happen to men than women. White or Native American people have higher rates of both compared to black or Asian people, and highest rates are found in those in their middle years, 41-64.

All mental health conditions are related to higher risk of unintentional overdose, as well as increased risk of suicide. Risks of both events are even higher in people with both mental illness and opioid use disorder.

Knowing the profiles of people at highest risk, can we use that data to intervene and prevent both causes of death? Yes, if they can access help. These patients do the best when both opioid use disorder and mental disorders are addressed at the same time.

Many prescription monitoring programs use numerous factors to determine who is at highest risk for overdose death. Those patients could be given more attention, with detailed assessment and referral to appropriate treatment.

North Carolina added an overdose risk score to its prescription monitoring program recently. It needs fine-tuning, since scores are adjusted upward for factors not always under a patient’s control. For example, I had a patient who is prescribed two Suboxone 8mg films per day. Her pharmacy doesn’t always have them in stock, forcing her to go to other pharmacies. When she does this, her overdose risk score goes up, but it’s not due to anything my patient is doing. In fact, instead of getting discouraged and giving up, she does what she needs to do to stay in treatment. That should adjust her score downward, in my opinion. But the data collectors at the state level have no idea why she’s at multiple pharmacies and assume it’s risky behavior.

I was happy to see this article emphasized the importance of increasing access to medication-assisted treatment for patients with opioid use disorder as a life-saving measure. Of course, they also emphasized a combined approach to treatment, with inclusion of evidence-based forms of counseling.

This study addresses the dilemma of the patient with chronic pain. We know that higher opioid doses are associated with increased risk of overdose death, but we don’t have data that shows tapering that dose reduces the risk of overdose or of suicide. Many practitioners now advocate reduction of patients’ opioid doses to at, or below, the 90 mg MME (morphine milligram equivalents) recommended by the CDC (Center for Disease Control and Prevention) for reducing risk. Might such a reduction make pain worse and trigger suicidal intent? We don’t know.

Some patients on chronic opioids develop hyperalgesia, a condition where the body becomes more sensitive to pain due to adaptations from chronic opioid use. Often those patients feel better as opioids are tapered, but this is far from a universal experience for pain patients.

What I learned from this article was that while we know pain, opioid use, suicidality, and opioid overdose are linked, we are far from understanding precisely how one condition influences the others. So far, we have developed profiles of patients most likely to be at risk, and we should be talking to those patients, doing better assessments. Then we need to increase access to care using evidence-based treatments.

We see the best outcomes when mental illnesses are treated along with opioid use disorders.

  1. Bohnert et al., “Understanding Links among Opioid Use, Overdose, and Suicide,” New England Journal of Medicine, January 3, 2019, pp71-79.

9 responses to this post.

  1. Posted by drkottaway on January 14, 2019 at 4:11 pm

    The data from the CDC in 2012 said that about 40% of the overdose deaths involving opioids were not high dose and were under the MME of 90. However, many involve other substances: alcohol, benzodiazepines, sleep meds and illegal drugs, soma and anything sedating. Thank for your article and the New England Journal reference!


  2. Posted by drkottaway on January 14, 2019 at 4:12 pm

    Oh, here is the CDC article from 2012:


  3. Posted by william taylor, MD on January 14, 2019 at 4:30 pm

    As far as pain patients: People with dreadful pain conditions are 1. at greater risk of suicide, and 2. on higher opiate doses. To blame the suicide risk on the opiate use and disregard the underlying arachnoiditis/Ehlers-Danlos/complex regional pain is to go seriously off the rails. Plenty of anecdotal evidence about pain patients becoming suicidal when confronted with forced tapers/doctors deciding not to give opiates/doctors forced out of practice. When Washington state regulators put Seattle Pain clinics out of business, they left thousands of pain patients without access to care. One well-documented suicide was described in a major article in the Seattle paper.


  4. Posted by william taylor MD on January 15, 2019 at 2:36 am

    The sad story is recounted in a Seattle Times article October 30, 2016. The patient’s name is Denny Peck. I’m not aware of any medical literature, although I’ve read a few of the blog postings that this issue occasioned. Also, the CDC guidelines have been robustly criticized; the AMA recently released a position paper saying that arbitrary dosage limits should not be used by law enforcement, regulatory agencies, or insurance companies to sanction physicians or limit care. In addiction medicine, doses 10 or 15 times the CDC limit are routinely and safely used for patients with no pain issues at all. Thank you for your always thoughtful commentary.


    • You’ve mentioned a significant problem – when medical guidelines are issued, groups with little or no medical training often adopt a “black and white” way of interpreting them, and interpret them more as regulations. It’s vexing, to understate. I’ll check out that article.


  5. Dr. Bursen,

    I had sent a response to one of your blogs about my situation as a Bus Driver and I was forced to resign because I was on suboxone. I have been on it successfully for many years with no illicit drug use. It has become more of a pain medication for me since I have RA. you responded to that blog, and said there are studies that have been done that show people on long term maintenance of suboxone with no illicit drug use have the same reaction times as normal people. Could you please guide me to these studies or the research that has been done. I am fighting this because I believe it was grossly unfair how this was handled.

    Thank you, James Woodall

    Sent from my iPad



    • here’s one: 2. The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving.
      Lenné, M., Dietze, P., Rumbold, G., Redman, J., & Triggs, T. (2003, December). Drug & Alcohol Dependence, 72(3), 271.
      Sounds like you need some legal help with this. If you can’t find an interested lawyer, you might try the ACLU in your state.


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