With deaths attributed to opioids increasing, some experts question if they are all accidental overdoses. Could some be suicides? Does chronic pain play a role?
Question 1. Between 1999 and 2016, the suicide rate in the US rose by approximately what percentage?
Answer: C. 30%. Between 1999 and 2016, the suicide rate increased by 30% with approximately 45 000 suicides in the US among persons aged ≥10 years in 2016 alone.1
Question 2. In 1999, the number of deaths from drug overdoses in the US was <20 000. What is the current annual number?
Answer: E. 70 000. Currently, the number of annual deaths from drug overdoses in the US is approximately 70 000. The greatest increase between 1999 and the present has been in deaths related to opioid overdoses.2
Answer: C. 20% to 30%. Between 2006 and 2011, 26.5% of opioid overdoses were classified as intentional.3
Answer: A. True. Chronic pain appears to be a predictor for suicide with the most common types identified being spine and musculoskeletal pain.4
Question 5. A study of notes left behind by those with a history of pain who committed suicide found pain cited as playing a role in the decision by which percentage?
Answer: E. 60% to 70%. A retrospective analysis of National Violent Death Reporting System data found that among those with a history of pain who committed suicide, 64.7% identified pain as playing a role in the decision.4
Answer: B. Firearms. As is true of suicide in the general population, the most common method used by decedents with chronic pain is firearms. However, among those with pain, opioid overdoses account for approximately 16% of deaths vs 4% among those without pain.4
Question 7. True or false? It has been proven that when doctors attempt to discontinue opioids prescribed long-term to patients with chronic pain, the pain inevitably worsens and significantly increases the risk for suicide.
Answer: B. False. In fact, research indicates that among patients with chronic non-cancer pain who are prescribed opioids, when the drugs are discontinued, on average the pain does not increase and in some patients there has been an improvement in the pain.5
Question 8. Approximately what percentage of all opioid overdose deaths also involve benzodiazepines?
Question 9. Among those with a history of pain who commited suicide, what percentage also tested positive for benzodiazepines?
Answer: D. 40% to 50%. Nearly half (47.2%) also tested positive for benzodiazepines.4 In most cases of chronic pain, benzodiazepines are contraindicated; among other dangerous interactions with opioids, they can reduce analgesia.7 In 2016, the FDA required labeling changes to alert prescribers against co-prescribing the 2 classes.8
Question 10. True or false? Research indicates that among patients with chronic non-cancer pain, those taking higher doses of opioids were at greater risk of death by suicide.
Answer: A. True. In a study of Veteran Health Affairs patients, the rates of suicide per 100 000 person years by any mechanism was ~43% when the maximum prescribed opioid dose was 1-20 mg vs 105% when the maximum dose prescribed was ≥100 mg/day.9
Answer: D. All of the above. Current research shows that the use of opioids by patients with pain can exacerbate comorbid depression; that opioids interfere with the efficacy of first-line antidepressant medications; and depression is associated with an increased risk for opioid use and dose escalation.10
1. Stone DM, Simon TR, Fowler KA, et al. Vital Signs: Trends in state suicide rates-United States, 1999-2016 and circumstances contributing to suicide-27 states, 2015. MMWR. 2018;67:617-624.
2. National Institute of Drug Abuse. Overdose death rates. https://drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Revised August 2018. Accessed November 16, 2018.
3. Tadros A, Layman SM, Davis SM, Davidov DM, Cimino S. Emergency visits for prescription opioid poisonings. J Emerg Med. 2015:49:871-877.
4. 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.
5. McPherson S, Smith CL, Dobscha SK, et al. Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain. 2018;159:2097-2104.
6. Gressler LE, Martin BC, Hudson TJ, Painter JT. Relationship between concomitant benzodiazepine-opioid use and adverse outcomes among US veterans. Pain. 2018;159:451-459.
7. Sun EC, Dixit A, Humphreys K, et al. Association between concurrent use of prescription opioids and benzodiazepines: Retrospective analysis. BMJ. 2017;356:j760.
8. Food and Drug Administration. FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use. https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm518697.htm. Published August 31, 2016. Accessed November 16, 2018.
9. Ilgen MA, Bohnert ASB, Ganoczy D, et al. Opioid dose and risk of suicide. Pain. 2016;157:1079-1084.
10. Mazereeuw G, Sullivan MD, Juurlink DN. Depression in chronic pain: Might opioids be responsible? Pain. 2018;159:2142-2145.
The increasing number of deaths attributed to opioid overdoses has been described as reaching epidemic proportions. Although the cause of death is believed in most cases to be an accidental overdose, there is a growing body of research indicating that a significant number may be suicides-and that chronic pain may play a role.Click through the 11-question quiz below to see how much you know about the link between opioids, suicide, and chronic pain.Â