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A Closer Look at Substance Use and Suicide

Michael Esang, M.B.B.Ch., M.P.H., Saeed Ahmed, M.D.

Suicide is the tenth leading cause of disorders, more suicide attempts, and that 24.5% of people aged 60–69 and
death in the United States across all age more frequent hospitalizations than pa- 13% of people aged 70–79 had consumed
groups. A total of 44,193 suicides occur tients with bipolar disorder alone (7). alcohol before attempting suicide (13).
each year, or 121 suicides per day (1). The Substance use independently in- Older persons use alcohol as a palliative
Centers for Disease Control and Preven- creases the risk of suicidal behavior (8). measure in response to pain, losses, and
tion defines suicide as “death caused by Acute and chronic drug abuse may im- affective changes. This often leads to a
self-inflicted injuries with the intention pair judgment, weaken impulse control, damaging cycle of alcohol use to self-
of dying from the result of such actions” and interrupt neurotransmitter path- medicate symptoms of depression, wors-
(1). Substance use is a risk factor for both ways, leading to suicidal tendencies ening the situation. For this reason, alco-
fatal and nonfatal overdoses, suicide at- through disinhibition (9). Additionally, hol use disorder has been reported to be
tempts, and death by suicide. Compared physiological and metabolic stress re- the second most common psychiatric
with the general population, individuals sulting from drug abuse can lead to neu- disorder associated with elderly suicide,
with alcohol dependence and persons rotoxic damage and other severe medical second only to depression (10, 13).
who use drugs have a 10–14 times greater complications. This is particularly sig-
risk of death by suicide, respectively (2), nificant in older populations who are less
and approximately 22% of deaths by sui- physiologically resilient due to increased
cide have involved alcohol intoxication chronic medical comorbidities and neu-
(2). Furthermore, one study found that rodegenerative diseases (10). In older Opioid-related suicides have doubled in
opiates were present in 20% of suicide populations, suicide is closely linked first the last 15 years. This increase has paral-
deaths, marijuana in 10.2%, cocaine in with psychiatric illness and subsequently leled the massive increase in drug over-
4.6%, and amphetamines in 3.4% (2). with substance use disorders, particu- dose deaths, particularly those involving
Among the reported substances, alco- larly alcohol use disorder. Therefore, prescription opioids. Prescribed opioid
hol and opioids are associated with the persons in this patient population have use nearly doubled between 1999 (116
greatest risks of suicidal behavior. a higher risk of suicidal behavior com- million) and 2011 (219 million) (14) and
Psychiatric disorders have a strong pared with younger individuals (9). has been noted to be a risk factor for sui-
association with suicide. Ninety percent cide by overdose. In 2015 alone, the Cen-
of people who die by suicide have one or ters for Disease Control and Prevention
more concomitant psychiatric disorders reported a total of 52,000 drug overdose-
(3). Suicide risk is highest among patients related deaths, with 63.1% involving a
with bipolar disorder (odds ratio=7.77) Drinking alcohol at an early age, binge or prescription or illicit opioid (15). The
and unipolar affective disorder (odds heavy drinking, and drinking behaviors rates increased to 72.2% for synthetic
ratio=6.67), followed by schizophrenia that meet criteria for mild, moderate, or opioids and were 20.6% for heroin. A
(odds ratio=6.55) and anxiety disorders severe alcohol use disorder can all lead meta-analysis by Wilcox and colleagues
(odds ratio=3.57–6.64) (4). The risk of to increased suicidal ideation. Persons (2) showed that heroin use increased the
suicide increases further when psychi- with heavy alcohol use are five times risk of suicide by 13.5 times compared
atric disorders are comorbid with sub- more likely to die by suicide than social with the 10-fold increase with alcohol
stance use disorders. Research shows drinkers (11). use disorder. Another study investigat-
that men with comorbid depression and In 2015, a survey conducted by the ing the association between prescription
alcohol use have the highest long-term Substance Abuse and Mental Health opioid use and suicide among patients
suicide risk (16.2%) (5). The prevalence Services Administration showed that with chronic noncancer pain revealed
of lifetime suicide attempts among pa- 9.8 million people ≥18 years old seri- that an increased opioid dose was related
tients with alcohol use disorder and bi- ously considered suicide in the past 12 to an increased risk of suicide, even after
polar disorder is reported to be between months, with 1.4 million making nonfa- controlling for demographic and clinical
21% and 42% (6). Similarly, patients tal suicide attempts (12). Young adults factors (16). The recent increase in drug
with bipolar disorder and comorbid sub- aged 18–25 were also more likely to have overdose-related suicides highlights the
stance use disorder have earlier-onset serious thoughts of suicide or suicide at- importance of assessing suicide risk in
mood symptoms, higher rates of anxiety tempts. One study of the elderly found patients receiving opioids.

The American Journal of Psychiatry Residents’ Journal  |  June 2018 6


BOX 1. Dynamic and Static Risk Factors Associated With Suicide and Protective Factorsa
Dynamic and Acute Risk Factors Static and Long-Term Risk Factors Protective Factors
Current suicidal ideation Family history Reasons for living
Current suicidal plan Caucasian race Being clean and sober
Preparation for suicide Unmarried status Attending 12-step support groups
Acute symptoms of mental disorder Living alone Religious attendance and/or internalized spiritual
Severe psychic anxiety Lack of social support teachings against suicide
Anxious ruminations Medical illness Presence of a child in the home and/or childrearing
Global insomnia Unemployment responsibilities
Psychosis with delusions of poverty or doom Fall in social or economic status Intact marriage
Active or recent alcohol abuse Rejection by spouse or partner Trusting relationship with a counselor, physician, or
Previous suicide attempts other service provider
Anniversary of important losses Employment
a For further details, see Simon (19).

OTHER SUBSTANCES, MULTIPLE The literature suggests numerous to make the patient aware of the process
SUBSTANCE USE, AND SUICIDE schemas to assist in evaluating individu- of rehabilitation. In the case of opioid use
als for potential suicide risks. One schema disorder, this can involve methadone and
Almost all substance use disorders are
categorizes risk factors as either dynamic buprenorphine treatments, which have
associated with an increase in suicide
(acute) or static (long-term) (see box). been shown to protect against suicide.
risk. Research shows that the suicide
Regarding patients who are suicidal and Methadone treatment in particular has
hazard ratio is 1.35 for cocaine use, 2.10
have a concurrent substance use disorder, been shown to make patients 20% less
for psychostimulant use, 3.83 for benzo-
clinicians should pay attention to dynamic likely to commit suicide (21). When treat-
diazepine use, 3.89 for cannabis use, and
risk factors that affect the individual’s life. ing patients with alcohol use disorder, a
11.36 for sedative use (8). Additionally,
These factors can change rapidly but are multilevel model of protection is recom-
marijuana use, cocaine use, alcohol use,
easy to target for treatment intervention. mended. This includes protecting against
and cigarette smoking were all found to
They include current misuse of alcohol biological, behavioral, environmental,
be independently related to suicide, even
and other drugs, concomitant depression, and cultural factors. Effective clinical
after controls for sociodemographic fac-
criminality, and difficulties in controlling care for patients with alcohol use disor-
tors (17). Tobacco use and smoking ap-
aggression and impulsivity. der as well as other psychiatric and med-
pear to contribute to deaths by suicide
The goal of intervention is to treat ical disorders will mitigate suicide risk,
(18). Current smokers are at the highest
acute, modifiable risk factors and to con- given the preponderance of evidence
risk of suicidal ideation, plans, and at-
tinuously ensure the patient’s safety (19). linking alcohol use disorder and suicidal
tempts, followed by past smokers, with
Patients at high risk for suicide should behavior. In addition, easy access to a va-
nonsmokers carrying the lowest risk.
be hospitalized as a precaution, and de- riety of clinical and nonpharmacological
Genetic vulnerabilities in the serotoner-
toxification treatment should be started interventions can be helpful. These in-
gic system may predispose a smoker to
immediately. Subsequently, it is crucial terventions may include psychotherapy,
suicide, although the exact mechanisms
have yet to be elucidated (18).
RISK ASSESSMENT AND • Collectively, substance use disorders confer a risk of suicide that is 10–14 times
MANAGEMENT greater than that of the general population; deaths related to substance use are
highest among persons with alcohol use disorders followed by persons who
Currently, no single rating scale or clini-
abuse opiates.
cal algorithm can accurately predict the
risk of suicide, because suicidal behavior • Patients with comorbid alcohol use disorder and a mood disorder have a great-
emanates from a convergence of multiple er risk of suicide attempts compared with patients with a mood disorder alone.
predisposing and concurrent risk factors. • Ongoing suicide risk assessment allows for an integrated treatment plan that
Even if all the scales were combined into enables the clinician to continuously address acute and modifiable suicide risk
a single risk assessment form, other clini- factors, such as preparatory behavior or acute psychosis, while identifying pro-
cal risk factors would be omitted (19). tective factors, which include spirituality, an intact marriage, and child-rearing
Furthermore, suicide is difficult to pre- responsibilities.
dict, as shown in one report suggesting
• The use of methadone and buprenorphine should be prioritized within an in-
that 83% of deaths by suicide were un-
tegrated treatment plan for patients with opioid use disorder to protect against
expected or unavoidable (20). Therefore, suicide; similarly, patients with alcohol use disorder require a multilevel ap-
reasonable clinical assessment and judg- proach, such as detoxification, attendance of rehabilitation programs, and en-
ment is key. gagement in recovery through follow-up programs.

The American Journal of Psychiatry Residents’ Journal  |  June 2018 7


motivational interviewing, cultural and Drs. Esang and Ahmed are third-year resi- 11. Harris EC, Barraclough B: Suicide as an out-
family engagement, fostering spiritual dents in the Department of Psychiatry at come for mental disorders: a meta-analysis.
Nassau University Medical Center, East Br J Psychiatry 1997; 170:205–228
beliefs, and limiting access to alcohol at
Meadow, N.Y. 12. Piscopo K, Lipari RN, Cooney J, et al: Sui-
the community level. Additionally, clini- cidal thoughts and behavior among adults:
cians should address coexisting smoking results from the 2015 National Survey on
The authors thank Dr. Anna Kim for her as-
addiction, because people with psychiat- Drug Use and Health. Rockville, Md, Sub-
sistance with this article.
ric disorders often have a truncated life stance Abuse and Mental Health Services
Administration, 2016
span due to smoking related diseases and
13. Frierson RL: Suicide attempts by the old and
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