Addressing Two Public Health Epidemics: Suicide and Opioid Addiction

A commentary article published in Preventive Medicine underscored the significant burden of suicide in patients with opioid use disorder. The study authors suggested a new intervention framework incorporating immediate risk factors for suicide rather than longitudinal risk assessment alone.

Sanchit Maruti, MD, MS, from the department of psychiatry, University of Vermont Medical Center in Burlington, and colleagues stressed the importance of raising clinician awareness about “internal and external conditions, very proximal to self-injury deaths” for suicide prevention in opioid use disorder. They described opioid use disorder as similar to walking on a tightrope across a canyon, with the risk for self-injury death as a sudden crosswind.

Traditionally, suicide and overdose prevention in opioid use disorder involves stratifying risk based on certain demographic and clinical factors. Investigators argue that this fails to capture the full picture. Instead, experts have identified the following “imminent” risk factors for a fatal outcome in patients with substance use disorders:

1. The presence of acute withdrawal or craving

2. Changes in patterns of use

3. Loss of agency, identity, or sense of belonging and the erosion of social supports, dysphoria, shame, humiliation, or insomnia

4. Increased use of other substances

5. Recent personal events, such as relapse, legal problems, or relationship conflict

The authors endorsed screening for suicidal ideation and its proximal factors using these criteria among individuals with opioid use disorder as part of standard care.

Large-scale prevention efforts exist for opioid use disorder and suicide risk, including through the National Strategy for Suicide Prevention and the Substance Abuse and Mental Health Services Administration. Even so, investigators advocated for additional public health efforts, among them research emphasizing the near-term risk factors for suicide and self-injury in opioid use disorder.

The study authors suggested formal suicide risk assessment with clear documentation for clinicians and organizations. Patients determined to be at risk should be provided with appropriate care, including inpatient hospitalization when necessary. Initial treatment must also be sensitive to comorbidities, including mental health conditions and other substance use disorders. At the community level, increased access to treatments must be provided, including medications for opioid use disorder, counseling, case management, vocational rehabilitation, and legal and housing assistance. Adequate follow-up is also necessary to monitor changes in proximal risk factors.

Increased focus on immediate risk factors for self-injury and overdose is critical to preventing opioid use disorder-related mortality. This focus on proximal risk factors necessitates improved community- and institution-level programs for opioid use disorder treatment. “Time is of the essence with assisting individuals who are either suicidal and/or in the midst of opioid misuse, in order to prevent opioid-related overdose and possibly, death,” the study authors wrote.

Disclosure: Several study authors declared affiliations with WISER Systems, LLC. Please see the original reference for a full list of authors’ disclosures.

Reference

Maruti S, Desjardins I, Bagge CL, Althoff RR. Commentary: opioid use disorder and suicide: an important opportunity to address two significant public health epidemics [published online October 21, 2019]. Prev Med. doi:10.1016/j.ypmed.2019.105854