We often speak about the opioid crisis and the suicide crisis – the parallel rises in the rate at which people are overdosing and taking their own lives – as if they are separate and distinct problems. According to Centers for Disease Control (CDC) data, the rate of fatal drug overdoses for 2017 was over 70,000, with 2/3 being opioid-related (49,000). The number of overdose deaths from all drugs and opioid, in particular, continues to break a new record every year. Meanwhile, suicides numbered over 47,000, a one-third increase over the past two decades. The demographic data hold all kinds of troubling trends, including suicide among the young and among women.
Many people’s overriding image of the opioid crisis is distinct from suicide: the patient in severe pain who gets prescribed too high a dose by a doctor or takes more than the doctor ordered to compensate for pain, accidentally overdosing as a result. Or the those who overdose from the lacing of “party drugs” with fentanyl. A 2015 study (reviewing hospital emergency room data) found that more than half of opioid deaths are, in fact, unintentional.
But is death by opioids a form of suicide? The same study found that over a quarter of overdoses were unambiguously suicides. The same study found that, in 20% of overdose deaths, it was impossible to determine. If we assume that the ambiguous cases stratify similarly to the clear accidents and clear suicides, then the rate is even higher: roughly 1/3 of overdoses as suicides and 2/3 as accidental. Assuming that 20,000 drug overdoses are suicides, then the 47,000 figure is undercounting the totality of America’ s suicide problem.
What can we learn from this data? Does it really matter why people are dying? While all of it is bad news, it’s critical to take some lessons away from how we respond to both public health challenges. The most basic takeaway is that the suicide crisis is embedded within the opioid crisis. This should not surprise anyone: between easy public access to heroin and fentanyl (just visit Craigslist) and the biochemical process of opioid overdose (a trifecta of euphoria, pain relief, and respiratory depression to the point of brain death), opioids are a relatively easy way to go. Some of the suicides might be people who are suffering from depression or other mental health issues and see opioids as an alternative, effective of taking their own lives (Growing recognition of opioids’ effectiveness as a means of death led Nebraska to become the first state to use opioids to carry out a death sentence in July 2018). Perhaps the most bitter irony of the denial of prescription opioids to people in severe chronic pain is that some people are taking their own lives with illegal opioids when they are denied access to legal ones.
If as many as a third of opioid overdoses are intentional, then another takeaway should be greater policy focus on addressing the underlying social and mental health issues driving the problem. When we examine the opioid policy response, much of the action has been focused on cracking down on doctors or biochemical response (drugs to prevent overdoses, like Narcan). These policy initiatives make sense if the central problem was unintentional overdoses. Based on the intentionality of some overdose deaths, however, these solutions are less relevant (in the case of Narcan) or actively harmful, in the case of the crackdown on doctor prescribing.
Meanwhile, it is hard to find much in the way of a policy response addressing the deep social crisis underlying intentional overdoses. Having sat at the table with federal policymakers, I am deeply troubled by the minimal level of attention spent examining how we address pervasive isolation, stress, and trauma, rising reported rates of anxiety and depression, and despair across America. Focusing on the opioid crisis as part of the suicide crisis and the suicide crisis as part of the opioid crisis means exploring how we address these underlying drivers. In The United States of Opioids, I argue that we cannot afford to wait for the government or our healthcare system to make this pivot. It is time for a grassroots action to address this within our homes, workplaces, school, religious communities, and in civic life.
What do we need to do? The more you study the data, it becomes clear that these crises are not easily reduced to one simple problem. They reflect multiple things going on at once. In a 2014 study of suicide and chronic pain, just under 9% of patients with suicide had evidence of chronic pain, but nearly 19% of patients without chronic pain tested positive for opioids. Mental health issues such as depression were a much more significant factor (present in over half of the suicides studied). The bottom line is that the decision a person makes to end his or her own life, and the interplay between pain and mental health issues is complicated. The important thing for us to remember is that the opioid crisis is not just about the people dying accidentally. It’s also people ending their own lives with opioids. Some of these are people cut off by their doctors. Many are people not getting access to effective social support and mental health resources. We have plenty of work ahead of us.
Harry Nelson is the author of The United States of Opioids: A Prescription for Liberating a Nation in Pain (2019) and co-author of From ObamaCare to TrumpCare: Why You Should Care. He is the founder of Nelson Hardiman, L.A.’s largest healthcare/life science law firm, where he advises on health regulatory and reimbursement issues.
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