The opioid epidemic in the United States has garnered widespread attention and substantial investments in prevention over the last decade as the number of opioid overdoses rose exponentially. The age-adjusted rate of overdose deaths increased by 9.6% from 2016 to 2017, resulting in 47 600 opioid-related overdose deaths in 2017.1 An increase in suicide deaths during the same time period mirrors the trend in opioid overdose deaths, yet it has received less national attention. The 47 173 suicide deaths in 2017 represent a 33% increase and the largest annual increase since 1999.2,3 Emerging data indicate that the increases in opioid overdose and suicide are interconnected,4 but strategies that address the intersections between opioid use, overdose, and suicide have been largely unexamined.
Both opioid overdose and suicide are serious and preventable public health issues. Sometimes collectively referred to as “diseases of despair,”5 they share several risk and protective factors and are closely interrelated. Individuals who experience a nonfatal opioid overdose face a significantly greater risk of later dying by suicide.6 According to the Substance Abuse and Mental Health Services Administration, opiates are present in 20% of suicide deaths in the United States.7 This interconnection points to the potential benefits of collaboration and coordination between opioid prevention and suicide prevention efforts, and it offers an opportunity for states to leverage the infrastructure built around the opioid response to comprehensively address suicide and overdose prevention.
US suicide rates increased by more than 25% between 1999 and 2015, with an estimated 1.3 million individuals attempting suicide and 44 193 dying by suicide in 2015.8 Although opioid-related suicides decreased from 9% to 4% between 2000 and 2017,9 their prevalence increased regardless of age, gender, race, or geographic region.10 Prescription opioids comprised most of the 20 917 opioid-related suicides between 1999 and 2014, and deaths were highest among white individuals aged 45 to 54 years living in the Western United States.3 These data indicate that public health leaders can more comprehensively address the opioid epidemic by concurrently promoting comprehensive suicide overdose prevention to address the intersecting needs of people at risk.
Comprehensive prevention incorporates upstream and downstream efforts across socioecological levels to mitigate risk factors and build protective factors.1 Shared risk factors for suicide and overdose include mental health disorders, substance use disorder, nonfatal overdose, suicidal ideation or attempts, intimate partner problems, poor social support, childhood trauma, and some chronic conditions.4,11–16 Growing research has identified the association between adverse childhood experiences and earlier initiation of opioid use,17,18 a greater likelihood of lifetime use,19 and an increased risk of suicide attempt,20,21 highlighting opportunities to build protective factors such as impulse control, anger management, and problem-solving skills during youth.22
However, current structures hamper comprehensive prevention. Various death certificate reporting standards and inadequate training for coroners and medical examiners make it difficult to accurately identify all opioid-related suicides.3,18,23 Furthermore, states report difficulty coordinating siloed suicide and opioid grants because of restrictive guidelines. Many of these grants fail to target middle-aged working males9,24 and individuals with chronic pain,10,25–28 the populations at a greatest risk for suicide overdose. States would benefit from efforts to build capacity and infrastructure to support data, leadership, partnerships, planning, and resources that treat opioid overdose and suicide as a syndemic with shared and synergistic risk and protective factors.
Public health agencies can invest in data and surveillance systems that capture timely and accurate trends in suicide and opioid overdose. Syndromic surveillance systems, which can provide data on nonfatal opioid overdose and self-harm in near real-time, offer opportunities to mobilize community responses to spikes and clusters. Mortality data systems also offer insights that can prevent opioid-related suicides. In 2018, the Centers for Disease Control and Prevention's National Violent Death Reporting System (NVDRS) was expanded to include data from all 50 states, Washington, District of Columbia, and Puerto Rico. NVDRS links multiple data sources including death certificates and toxicology and medical examiner and coroner reports to examine factors that have led to death.29 A recent study using NVDRS data determined that opioid-related suicide rates were estimated to be underreported in 33% of cases.30
Many states have additionally authorized the use of overdose fatality review teams, sometimes known as a “social autopsies,” to examine population and individual factors for opioid-related deaths. Expanding social autopsies to examine overlapping factors with suicide would provide richer contextual data to drive more comprehensive policy recommendations and prevention efforts. Improving the quality and timeliness of fatal and nonfatal opioid-related suicide data, and further cross-analyzing opioid and suicide data, could help states message the importance of the intersection to leadership, stakeholders, communities, and legislators.
Comprehensive programs and initiatives that simultaneously address opioid misuse, overdose, and suicide require engagement and support from key state leadership. State health officials, as chief health strategists and conveners, play a critical role in driving the innovation needed to address diseases of despair through policy. Although the structural relationships between public health, behavioral health, and other necessary state and local partner agencies can pose challenges to alignment, leaders who are committed to developing relationships, communicating, and sharing resources can successfully bridge these efforts. Comprehensive initiatives will be most effective when these leaders engage laterally with their counterparts in other agencies to focus on developing momentum and maintaining progress. One approach to establishing a leadership team that spans laterally and vertically to address deaths of despair would be to identify state-, local-, and community-level suicide and opioid overdose prevention leaders, build and strengthen connections among those leaders, and plan for collaboration and coordination as efforts proceed.
To strengthen partnerships between public and behavioral health, state agency leaders can remove barriers to partnership, engage stakeholders, and demonstrate the need for aligning public health and behavioral health priorities. Barriers to partnership include organizational and funding barriers,7 and organizational barriers exist because opioid overdose prevention and suicide prevention are rarely priorities of the same agency. Funding mechanisms reinforce these organizational barriers, as funding streams are usually disbursed to a single state agency or tribal government.
One approach for overcoming funding and organizational barriers is forming an interagency overdose and suicide prevention council or workgroup that convenes stakeholders across agencies and organizations, promotes collaboration among these stakeholders, and coordinates funding from different sources. State agency leaders can also engage other stakeholders, such as state legislators, academic partners, medical providers, harm-reduction coalitions, other community groups, and suicide prevention and opioid task forces.31 Finally, state agency leaders must demonstrate the need for aligning public health and behavioral health priorities related to opioid overdose and suicide prevention, given the significant overlap in strategies for addressing them.
In strategic planning, state agency leaders must develop suicide and overdose prevention plans collaboratively so that the plans reflect some level of integration.29 Strategic plans must also be responsive and updated regularly to reflect changes in context.32 Updates to strategic plans must be coordinated by entities involved in both opioid overdose and suicide, since changing one plan often requires changing another. To ensure that strategic plans are dynamic, living documents, state agency leaders must establish a process for continuous planning and collaboration. The more dynamic and nimble the plan is, the more likely it is to effectively address the impacts of opioids and suicide.
In 2018, the federal government directed an estimated $7.4 billion to address the opioid epidemic.33 During the same year, the federal government directed approximately $61 million for suicide prevention.34 This indicates a need to leverage and diversify funding in a way that allows for comprehensive prevention. Strategies for effectively managing resources related to preventing deaths of despair include assessing funding mechanisms for opioid misuse and suicide prevention, identifying opportunities to address shared risk and protective factors, cross-training program staff, building social capital, and aligning funding with capacity needs.
A comprehensive approach that seeks to understand and address the intersection of opioid use, overdose, and suicide would bolster states' efforts to mitigate the effects of diseases of despair in their communities. Key to this approach are building capacity for timely and accurate data, engaging and supporting key leadership and decision makers, establishing cross-priority partnerships, and better leveraging and diversifying funding aimed at preventing opioid misuse and suicide.
1. Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths—United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;67:1419–1427.
2. Heron M. Deaths: Leading Causes for 2017. Vol 68. Hyattsville, MD: National Center for Health Statistics; 2019. National Vital Statistics Report No. 6.
3. Hedegaard H, Curtin SC, Warner M. Suicide Mortality in the United States, 1999-2017. Hyattsville, MD: National Center for Health Statistics; 2018. NCHS Data Brief No. 330.
4. Maloney E, Degenhardt L, Darke S, Nelson EC. Are non-fatal opioid overdoses misclassified suicide attempts? Comparing the associated correlates. Addict Behav. 2009;34(9):723–729.
5. Shanahan L, Hill SN, Gaydosh LM, et al. Does despair really kill? A roadmap for an evidence-based answer. Am J Public Health. 2019;109(6):854–858.
6. Olfson M, Crystal S, Blanco C. Causes of death after nonfatal opioid overdose. JAMA Psychiatry. 2018;75(8):820–827.
7. Substance Abuse and Mental Health Services Administration. Substance Use and Suicide: A Nexus Requiring a Public Health Approach. In Brief. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2016. https://store.samhsa.gov/system/files/sma16-4935.pdf
. Accessed February 10, 2020.
8. Ports KA, Merrick MT, Stone DM, et al. Adverse childhood experiences and suicide risk: toward comprehensive prevention. Am J Prev Med. 2017;53(3):400–403.
9. Olfson M, Rossen LM, Wall MM, Houry D, Blanco C. Trends in intentional and unintentional opioid overdose deaths in the United States, 2000-2017. JAMA. 2019;322(23):2340–2342.
10. Braden JB, Edlund MJ, Sullivan MD. Suicide deaths with opioid poisoning in the United States: 1999-2014. Am J Public Health. 2017;107(3):421–426.
11. Oliva EM, Bowe T, Tavakoli S, et al. Development and applications of the Veterans Health Administration's Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide. Psychol Serv. 2017;14(1):34–49.
12. Yuodelis-Flores C, Ries RK. Addiction and suicide: a review. Am J Addict. 2015;24:98–104.
13. Bohnert ASB, Roeder K, Ilgen MA. Unintentional overdose and suicide among substance users: a review of overlap and risk factors. Drug Alcohol Depend. 2010;110(3):183–192.
14. Kuramoto SJ, Chilcoat HD, Jo J, Martins SS. Suicidal ideation and suicide attempt across stages of nonmedical prescription opioid use and presence of prescription opioid disorders among U.S. adults. J Stud Alcohol Drugs. 2012;73(2):178–184.
15. Finkelstein Y, Macdonald EM, Hollands S, et al. Risk of suicide following deliberate self-poisoning. JAMA Psychiatry. 2015;72(6):570–575.
16. Petrosky E, Harpaz R, Fowler KA, et al. Chronic pain among suicide decedents, 2003 to 2014: findings from the National Violent Death Reporting System. Ann Intern Med. 2018;169:448–455.
17. Stein MD, Conti MT, Kenney S, et al. Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder. Drug Alcohol Depend. 2017;179:325–329.
18. McManama O'Brien KH, Salas-Wright CP, Vaughn MG, LeCloux M. Childhood exposure to a parental suicide attempt and risk for substance use disorders. Addict Behav. 2015;46:70–76.
19. Dube SR, Felitti VJ, Dong M, Chapman DP, Giles WH, Anda RF. Childhood abuse, neglect, and household dysfunction and the risk of illicit drug use: the Adverse Childhood Experiences Study. Pediatrics. 2003;111(3):564–572.
20. Dube SR, Anda RF, Felitti VJ, Chapman DP, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA. 2001;286(24):3089–3096.
21. Thompson MP, Kingree JB, Lamis D. Associations of adverse childhood experiences and suicidal behaviors in adulthood in a U.S. nationally representative sample. Child Care Health Dev. 2019;45(1):121–128.
22. Compton WM, Jones CM, Baldwin GT, Harding FM, Blanco C, Wargo EM. Targeting youth to prevent later substance use disorder: an underutilized response to the US opioid crisis. Am J Public Health. 2019;109(S3):S185–S189.
23. Rockett IRH, Caine ED, Connery HS, et al. Discerning suicide in drug intoxication deaths: paucity and primacy of suicide notes and psychiatric history. PLoS One. 2018;13(1):e0190200.
24. Bohnert ASB, Ilgen MA. Understanding links among opioid use, overdose, and suicide. N Engl J Med. 2019;380:71–79.
25. Sansone RA, Watts DA, Wiederman MW. Pain, pain catastrophizing, and history of intentional overdoses and attempted suicide. Pain Pract. 2014;14(2):E29–E32.
26. Campbell G, Bruno R, Darke S, et al. Prevalence and correlates of suicidal thoughts and suicide attempts in people prescribed pharmaceutical opioids for chronic pain. Clin J Pain. 2016;32(4):292–301.
27. Cheatle MD. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011;12(2):S43–S48.
28. Cheatle MD. Assessing suicide risk in patients with chronic pain and depression. J Fam Pract. 2014;63(6)(suppl):S6–S11.
29. Centers for Disease Control and Prevention. National Violent Death Reporting System (NVDRS). Violence prevention. Injury center. https://www.cdc.gov/violenceprevention/datasources/nvdrs/index.html
. Published November 7, 2019. Accessed February 12, 2020.
30. Liu D, Yu M, Duncan J, Fondario A, Kharrazi H, Nestadt PS. Discovering the unclassified suicide cases among undetermined drug overdose deaths using machine learning techniques. Suicide Life Threat Behav. 2019. doi:10.1111/sltb.12591.
31. Franklin G, Sabel J, Jones CM, et al. A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned. Am J Public Health. 2015;105(3):463–469.
32. Lavinghouze SR, Snyder K, Rieker PP. The component model of infrastructure: a practical approach to understanding public health program infrastructure. Am J Public Health. 2014;104(8):e14–e24.
33. Bipartisan Policy Center. Tracking federal funding to combat the opioid crisis. https://bipartisanpolicy.org/wp-content/uploads/2019/03/Tracking-Federal-Funding-to-Combat-the-Opioid-Crisis.pdf
. Published March 2019. Accessed February 13, 2020.
34. Substance Abuse and Mental Health Services Administration. SAMHSA awards $61.1 million in suicide prevention funding. https://www.samhsa.gov/newsroom/press-announcements/201809211000
. Accessed February 13, 2020.