Do Opioids Raise or Lower Risk of Suicide?

By Pat Anson, Editor

Robert Rose has little doubt what the fallout will be from tougher guidelines for opioid pain medication being adopted by the Departments of Defense and Veterans Affairs. The 50-year old Marine Corps veteran calls the guidelines a “death sentence” for thousands of sick and wounded veterans like himself.

“Suicides are going to increase. No doubt about it. Alcoholism is going to increase. Veterans dying from accidental overdoses are going to increase. Deaths caused by veterans turning to street drugs are going to increase,” says Rose.

The VA and the Pentagon released the new opioid guidelines for veterans and active duty service members last month. (See “Tougher Opioid Guidelines for U.S. Military and Veterans”). It urges VA and military doctors to taper or discontinue opioids for patients on high doses, and strongly recommends that no opioids be prescribed for chronic pain patients under the age of 30.

Some VA doctors didn’t wait for the new guideline to be released. Rose, who suffers from chronic back pain due to service related injuries, was on a relatively high dose of morphine for 15 years before he was abruptly taken off opioid medication by his doctor last December.

Rose is in so much pain now that he rarely leaves the house.

“People cannot live in the amount of pain that I’m doing. They can’t do it. It’s just unimaginable to think that people can survive at this level for any length of time and be denied pain care,” Rose told PNN.

“Many, many, many days I was asking God to take me home because I couldn’t deal with the pain anymore.”

robert rose

robert rose

Suicidal thoughts are not uncommon in the veteran community. Over half the veterans being treated at VA facilities suffer from chronic pain, as well as high rates of depression and post-traumatic stress disorder.  A recent study by the VA estimated that 20 veterans killed themselves each day in 2014.

Some have associated the high rate of suicide with opioid pain medication. The new VA guideline recommends that patients be closely monitored for suicide risk during opioid therapy, especially if they have a history of depression or bipolar disorder.

But there is no mention in the 192-page guideline that undertreated or untreated pain can also be a risk for suicide. The guideline is actually dismissive of suicide risk in patients being weaned off opioids:

“Some patients on LOT (long term opioid therapy) who suffer from chronic pain and co-occurring OUD (opioid use disorder), depression, and/or personality disorders may threaten suicide when providers recommend discontinuation of opioids. However, continuing LOT to ‘prevent suicide’ in someone with chronic pain is not recommended as an appropriate response if suicide risk is high or increases.”

Do Opioids Raise Risk of Suicide?

Are suicidal patients better off without opioids, as the guideline suggests?

“When I’m doing clinical work, that’s a question that I face on almost a daily basis,” says Mark Edlund, MD, a Utah psychiatrist who treats patients with chronic pain, mental health and substance abuse problems. “If people are being prescribed opioids, does that increase their risk for suicide?”

Edlund co-authored a recent study published in the American Journal of Public Health, which found that the number of suicides involving opioids more than doubled from 1999 to 2014, a period when opioid prescribing sharply increased.     

“There’s a good theoretical reason to think they are linked. Opioids can easily cause death. We know that opioid prescriptions have been going up,” says Edlund. “To me the results make complete sense. And they fit within a model you could make of increased access to opioids would increase suicide.”

Edlund, who is a research scientist with RTI International, co-authored the study with Jennifer Braden, MD, and Mark Sullivan, MD, both researchers at the University of Washington. Sullivan is a longtime critic of opioid prescribing practices and a board member of Physicians for Responsible Opioid Prescribing (PROP), an anti-opioid activist group.

Edlund is not a member of PROP, but has participated in some PROP research studies and says he is "largely in agreement" with the group's goals.

While his study found an association between opioid medication and suicides, Edlund admits it failed to prove causation – definitive proof that opioids contribute to suicidal thoughts or actions. In fact, recent research indicates that less than 5 percent of the attempted suicides in the U.S. involve opioids.  

“If you really wanted to get into causality, that would be very difficult to assess,” he said.  “I think there are competing explanations. What may be true for one person may not be true for another. Maybe for some people opioids are not helping with their pain and they’re worsening depression. But on the other hand, I’m sure there are some people that are using opioids and it improves their functioning and decreasing their pain. That part is hard to disentangle.”

The United States has seen a disturbing increase in suicides for over a decade. In 2014, nearly 43,000 Americans committed suicide, over twice the number of deaths linked to accidental opioid overdoses.

Most often suicides are blamed on depression, mental illness, financial problems, or drug and alcohol abuse. No statistics are kept on how many Americans kill themselves due to untreated or poorly treated pain, but there are a growing number of anecdotal reports of patients killing themselves after having their opioids reduced or eliminated (see “Chronic Pain Patient Abandoned by Doctor Dies”).

“I can't go on like this,” Bianca recently wrote to PNN. “They've cut my medicine to less than half of what I was taking.  I also have had suicidal thoughts, but pray to God that I don't.”

“I think of killing myself every day since… my doctors stopped prescribing (opioids). Why have they not been looking at this very issue, which is pain?” asked Tom.

“I will kill myself if they take me off it. Barely helps my pain anyways. The new anti-opiate laws by the government will cause my death,” wrote another pain patient. “I am certain many others will commit suicide.”

“I have suicidal thoughts every day since being taken off opioids. Life was bad before, now it is hell,” said Thomas. “Let’s place an ice pick in these doctors’ spines and see how long they last 24 hours per day, seven days a week. These ivory tower idiots would have a quick change of mind.”

Those are the patients that Mark Edlund worries about.

“That’s the personal clinical issue that I wrestle with. Which of those patients that I see will the opioid increase risk of suicide or decrease it? If it’s a legitimate pain patient who benefits from opioids, then yeah, it’s going to decrease the risk,” he said.

Do Opioids Lower Risk of Suicide?

Researchers in Israel recently found that very low doses of an opioid actually reduce suicidal thoughts. Patients in four Israeli hospitals – most of whom had a history of suicide attempts – had a significant decline in suicidal ideation after being given tiny doses of buprenorphine (Suboxone), a medication widely used to treat addiction.

“The study could not prove that opioids treat mental pain—it wasn’t designed to do so—but it did show that buprenorphine decreases suicidal ideation.  Perhaps the study’s most important contribution is its implication that treatments that help us withstand mental pain may prevent suicide,” psychiatrist Anne Skomorowsky wrote in Scientific American.

“(The) study provides a rationale for thinking about opioids in a new way. More than that, it suggests that interventions that increase our capacity to tolerate mental anguish may have a powerful role in suicide prevention.”

Suicide is a topic that is rarely addressed in the national debate over the so-called opioid epidemic. But as efforts continue to restrict or even eliminate opioid prescribing, patients like Robert Rose warn that we could be exchanging one epidemic for another.

“Them taking the pain meds away (from me) was God kicking me in the ass and telling me to get back into the world of the living. Now I have something to fight for,” says Rose, who bombards politicians, government officials and regulators with a steady stream of emails warning of the harm opioid guidelines are causing.

“Unfortunately since the VA adopted the CDC guidelines this is exactly what many veterans have done… turned to suicide. And with Medicare/Medicaid considering adopting the same policies, those suicides, your families, friends and neighbors, will spill over into the civilian populace with staggering implications for many,” Rose said in a recent email.

“Instead of tens of thousands of veterans being affected, it’s going to be tens of millions. And the loss of life is going to be devastating to families, communities and to the workforce.”