In 2021, the U.S. suicide rate returned to its 2018 peak (Centers for Disease Control and Prevention, 2023). In the U.S., there were 48,000 suicide deaths in 2021.

Rates of opioid-involved overdose deaths have reached unprecedented levels since the onset of the COVID-19 pandemic. In 2020 in the U.S., there were 68,630 opioid-involved overdose deaths, which accounted for almost 75% of all drug overdose deaths (Centers for Disease Control and Prevention, 2023).

Investigating and addressing the nexus of these crises is a key priority area for research, policy, and service delivery to reduce the risk of suicide among opioid users (Bohnert & Ilgen, 2019; Oquendo & Volkow, 2018).

What accounts for the relationship between suicide behavior and opioid use?

Up to 50% of heroin users and 15% of prescription opioid users attempt suicide. Rates of suicide death in opioid users are lower, albeit still high, at 10% to 30% (Darke, Farrell, and Lappin, 2023). This suicide rate is higher than the suicide rate in the general population and on par with suicide rates among individuals with psychiatric disorders that carry the highest suicide risk. Conversely, in a recent study of suicide deaths in Maryland, opioid use was implicated in 12% of suicides. There are a number of explanations for the co-occurrence of suicide and opioid use. They include the following:

1. Psychosocial features among individuals who use opioids and those at risk for suicide overlap. Shared features in these populations include: poor psychosocial health, including psychiatric and medical disorder, relatively (compared to the general population) high rates of other substance use, pain, suicide ideation, isolation, loneliness, and hopelessness. Importantly for suicide prevention efforts among opioid users, opioid use may instantiate risk for suicide behavior beyond that conferred by shared risk factors for both outcomes (Chesin et al., 2019). In the 24 hours subsequent to opioid misuse, the risk of a suicide attempt more than doubles (Bagge & Borges, 2017). Taken together, a clear association between opioid use and acute as well as longer-term vulnerability to suicide exists.
2. Difficulties finding and engaging in treatment are also common among individuals with suicide behavior and/or opioid use and contribute to risk (Kline et al., 2023). Many suicide attempters who present to and receive treatment in acute care settings do not engage in outpatient treatment following discharge (Lizardi & Stanley, 2010). Patients with opioid use disorder discharging from inpatient treatment are also unlikely to engage in continuing care to poor effect (Naeger et al., 2016). On the supply side, access to medications to treat opioid use disorders or otherwise specialized services to reduce or stop opioid use are often limited (Presnall et al., 2022). Providers with specialty training, credentialing, and comfort in treating suicidal patients are also scarce.
3. Shared environmental risk factors for suicide and opioid use include access to lethal means, e.g., prescribed or illicit opiates.

Such overlap suggests suicide prevention among opioid users could be bolstered by targeting shared risk factors and treatment engagement, as well as increasing clinical training on specialized treatments to prevent suicide and opioid use.

What limits our understanding and therefore ability to prevent suicide among those who use opioids?

1. Misclassification of death and self-injurious behavior occurs. Unintentional opioid overdose deaths, for example, are hard to distinguish from opioid-involved suicide deaths because behavioral intent can be ambiguous or unknown.
2. An incomplete understanding of substance use among suicide attempters exists due to incomplete data collection and reporting of substance use by suicide attempt survivors. Such limitations undermine understanding of the magnitude of opioid-involved suicide behaviors.
3. Most current research on suicide and opioid use is cross-sectional, meaning study subject data is collected at one time point. This prohibits understanding of temporal relationships between opioid use and suicide behavior, as well as how and when factors associated with these outcomes (e.g., loneliness, hopelessness, and psychiatric disorder) contribute to risk.
4. It may be that only more significant opioid use (in terms of frequency or amount) or opioid misuse (e.g., heroin use or illicit use of a prescribed opioid) is robustly linked to suicide behavior. The lack of definitional consistency and specificity of opioid use undermines understanding of the link between opioid use severity and suicide behavior, and ultimately understanding of who among opioid users is at highest risk for suicide.

What can be done to prevent suicide among opioid users?

1. Lethal means restriction. In suicide prevention, lethal means restriction, i.e., removal or restriction of means to die by suicide, is done at the individual level, and is an effective suicide prevention strategy (Zalsman et al., 2016). At a macro-level, data show positive links between opioid prescriptions per capita and suicide deaths (Olfson et al., 2023 ).
2. Improved screening for risk and greater availability of specialized treatment targeting both opioid use and suicide risk. It follows from the relatively high rates of suicide behavior among those with opioid use that screening for suicidal thoughts and behaviors in individuals who present with current or past opioid use is indicated. While clinical workforce development in effective treatment of both opioid use and suicide behavior is needed, in the meantime, there are publicly-available resources, such as SAMHSA’s TIP 50: Addressing Suicidal Thoughts and Behaviors in Substance Abuse Treatment.
3. More research. Studying individuals who may be vulnerable to opioid use and suicide behavior over time would allow for better understanding of how to effectively prevent opioid use and suicide behavior. There are practical reasons why such study is hard to come by, e.g., availability, or lack thereof, of study subjects over time. But, ultimately, a better understanding of risk and environmental factors that contribute to risk will help mitigate the current suicide and opioid crises that account for over 116,000 deaths annually in the U.S.