Over the past few years the escalating opioid crisis has touched off a complex debate about how best to reign in suicide risk among patients who are prescribed the addictive painkillers.
The question: Could rapidly cutting back on legal opioid prescriptions help, or might patients’ desperation over lack of access inadvertently drive up suicide risk?
Now new research suggests that opioid prescription rates and suicide risk appear to go hand-in-hand. As prescription rates fall, so does suicide risk.
“People who are prescribed opioids, especially at higher doses, are at increased suicide risk,” said lead author Dr. Mark Olfson, a professor of psychiatry, medicine and law at Columbia University Irving Medical Center in New York City.
Roughly 4 in 10 overdose suicide deaths across the U.S. involve opioids, Olfson pointed out. And suicide risk is twice as high among patients prescribed high-dose opioids as among those who receive low-dose options.
But the role of legal prescribing patterns has been a matter of controversy and competing considerations, he said.
“On one hand, increasing opioid prescriptions might increase suicide risks by expanding access to medications that are potentially fatal when mixed with other drugs — such as benzodiazepines — or when taken in excess.” Olfson said, adding that opioids also increase depression risk in some people.
“On the other hand, lowering the dose of opioids too quickly or preventing people with unbearable pain from receiving adequate pain control with opioids could lead them to become desperate and perhaps even suicidal,” he said.
To learn more, Olfson and his colleagues combed U.S. federal government data collected between 2009 and 2017 on opioid-related deaths. That data was cross-referenced with information that tracked opioid prescription patterns over the period.
Researchers divided the U.S. into roughly 900 regions, to see how shifts in each region’s opioid prescribing appeared to affect its opioid-related suicide rate.
Regions that had the greatest decline in opioid-prescribing rates also had the greatest declines in suicide rates, according to the study. These links tended to be strongest in Western states.
Overall, opioid prescribing dropped during the study period on a variety of measures.
Declines were seen in prescriptions for high-dose opioids and in the practice of prescribing opioids for long periods. “Opioid-shopping” — obtaining prescription opioids from more than one doctor — also declined over the study period.
“We found that regions with the greatest declines in people filling opioid prescriptions also tended to have the greatest decreases in suicide deaths,” Olfson said. “This suggests restraining opioid prescribing helped lower risk of suicide.”
The finding, however, came with a caveat: Between 2009 and 2017, the overall suicide rate actually rose. While the suicide rate 13.8 for every 100,000 Americans in 2009, it rose to 16.4 by 2017.
But Olfson said that his team concluded that the drop in opioid prescribing trends actually slowed the rise in suicide risk. “Had this decrease in opioid prescribing not occurred, suicide rates would have increased even faster than they did,” he stressed.
Still, an outside expert cautioned that the findings do not prove that lowering opioid prescriptions can actually reduce suicide risk. They only show a link between the two.
“For those who have wondered whether curtailing opioid prescriptions could be associated with an increased risk of suicide, this study is reassuring,” said Dr. Kanu Okike, an associate professor of orthopaedic surgery with Kaiser Moanalua Medical Center in Honolulu.
“However, further research is required to determine whether the lower number of opioid pain medication prescriptions is causing a lower rate of suicide or if it merely represents an association due to other factors, such as depression,” he added, after reviewing the findings.
Pat Aussem is associate vice president of consumer clinical content development with the Partnership to End Addiction in New York City.
While reducing opioid prescriptions is one tool to reduce suicide risk, it needs to be part of a “holistic approach to well-being,” she said.
“Limiting opioid prescriptions in addition to the amount of opioid medications prescribed and drug takeback initiatives are helpful in terms of reducing the associated risks not only for suicidality but also for addiction, unintentional overdoses and death,” said Aussem, who wasn’t involved with the study.
But she added that such moves on the prescription front must be accompanied by “improving strategies for pain management, using non-opioid therapies where possible, screening for mental health and substance use risk, [and] encouraging the safe disposal of unused or expired medications.”
Whenever opioid prescriptions are issued, Aussem said, patients should also be provided naloxone, a nasal medication that can rapidly halt an overdose and restore normal breathing to patients in trouble.
The findings were published April 11 in the American Journal of Psychiatry.
Read more about opioid use and suicide risk at the U.S. Department of Veterans Affairs.
SOURCES: Mark Olfson, MD, MPH, professor, psychiatry, medicine and law, Columbia University Irving Medical Center, and research psychiatrist, New York State Psychiatric Institute, New York City; Kanu M. Okike, MD, MPH, associate professor, orthopaedic surgery, Kaiser Moanalua Medical Center, Honolulu; Pat Aussem, LPC, MAC, associate vice president, consumer clinical content development, Partnership to End Addiction, New York City; American Journal of Psychiatry, April 11, 2023
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