Integrate Suicide Prevention into Treatment for OUD Patients

The Surgeon General’s Call To Action To Implement the National Strategy for Suicide Prevention highlights deficiencies in our actioned public health responses to preventable self-injury deaths, which have accelerated over the past 20 years. This call to action is particularly important for clinicians and community stakeholders working to bend the curve on drug overdose deaths, especially opioid overdose deaths—the main driver of drug overdose fatalities—which are estimated to be ever increasing. This is occurring despite concerted national efforts to increase uptake of medications for opioid use disorder, which include methadone, buprenorphine, naltrexone, and to disseminate life-saving naloxone opioid overdose reversal medications, as well as to provide greater harm reduction opportunities to those with drug use disorders.

Why would suicide prevention be considered meaningful in the context of the opioid epidemic?

There is long-established evidence that suicide risk is associated with opioid use disorder (OUD), and more recently increasing evidence that suicidality is a national driver of both pain-associated opioid analgesic overdose fatalities and depression-associated illicit opioid fatalities. It appears that the COVID-19 pandemic has only added to risk.

What do we know with certainty about opioids and suicide risk?

• Opioid users have 3 times the risk for overdose and suicide compared to those without opioid use, whether young adult or late-life adult.
• Significant opioid exposure is associated with increased suicide thoughts, planning and behaviors. This is true whether the opioid is an analgesic or an illicit drug, and whether exposure is due to addiction or to chronic pain.
• Among all suicide poisoning attempts, those who attempt with opioids are 5 times more likely to die.

That should probably be enough to be convincing. But for those who treat OUD, here are a few more things to consider:

• Rates of suicide in individuals with OUD are up to 14 times greater than the general population.
• Among OUD patients seeking treatment, 30-45% report a prior suicide attempt.
• There is emerging evidence that opioid overdose deaths contain a significant percentage of people who had desire or intention to die before they overdosed on opioids.
• Those with OUD commonly have a history of trauma, depression and anxiety, and associated increased risk for suicide, especially in the absence of quality mental healthcare.

Given what is currently understood about the suicide risk among those with opioid misuse and OUD, it is only logical that suicide screening and prevention be integrated into care. For many clinicians and other community stakeholders, this is a stressful proposition: How can I/we hold responsibility for preventing a person from killing him/herself? What if I miss it? What if what I do doesn’t work? What if a person who tells me they want to die, talks to me for an hour and accepts local supports, leaves my session and just kills him/herself? Do I lose my license? Can I live with that loss without feeling like it was my fault?

These thoughts are indeed the barrier to national suicide prevention implementation and to OUD care implementation. The reality is anyone providing care for substance use disorder is already contending with a career fraught with the discomfort of caring for those capable of fatal self-injury. Suicide is just one form of this, severe OUD is another. Science comes to aid us in these risky places, by guiding us with evidence-based practices demonstrated to save lives and to reduce suffering. Suicide prevention algorithms—based in alliance with a person and careful construction of personalized safety plans—are as well-described as prescriber algorithms for MOUD and naloxone rescue.

We need to embrace these now as an urgently needed aspect of bending the curve on drug overdose deaths.

Hilary S. Connery, MD, PhD, is clinical director for the Center of Excellence in Alcohol, Drugs and Addiction at McLean Hospital.