understanding the connection: suicide, opioid … · (case & deaton, 2017) in all-cause...

UNDERSTANDING THE CONNECTION:

SUICIDE, OPIOID OVERDOSE, AND

OPIOID ABUSE

Kristen Quinlan, Ph.D.Epidemiologist, Suicide Prevention Resource CenterDirector of Outreach, Injury Control Research Center for Suicide Prevention

www.theactionalliance.org

www.edc.org

http://www.theactionalliance.org/

http://www.edc.org/

Road Map

Information on suicide: Who is at risk?What do our state-level data say?

Information on opioid overdose and opioid abuse:Who is at risk?What do our state-level data say?

Understanding the connection between opioid overdose, opioid abuse, and suicide

Understanding the implications for prevention

Understanding the connection: suicide and opioid abuse/overdose3

The River

(McKinlay, 1979)

INFORMATION ON SUICIDE


Suicidal Behaviors

47,173Deaths

2017(Adults & Youth)

9,829,000Serious Thoughts of Suicide, 2016, Past 12-months (Adults)

1,319,000Suicide Attempts 2016,

Past 12 months (Adults)

1NSDUH, 2017. 2Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2017. Understanding the connection: suicide and opioid abuse/overdose

6(CBHSQ, 2017; CDC, 2016)

NATIONAL ACTION ALLIANCE FOR SUICIDE PREVENTION 7

Who is at risk for suicide death? Looking at men and women.

Age Adjusted Suicide Death Rate Per 100,000 in US and KY, by Sex. 2012-2016

(CDC, 2016)

0

5

10

15

20

25

30

2012 2013 2014 2015 2016

Men (KY) Women (KY) Men (US) Women (US)

MEN (KY)

MEN (US)

WOMEN (KY)WOMEN (US)

Who is at risk for suicide death? Looking at race.


Age Adjusted Suicide Death Rate Per 100,000 in US, by Race, 2016

0

2

4

6

8

10

12

14

16

White Black AI/AK Asian/PI

(CDC, 2016)

Who is at risk for suicide death? Looking at age.

Understanding the connection: suicide and opioid abuse/overdose9(CDC, 2016)

0

5

10

15

20

25

30

35

15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79

KY US

Crude Suicide Death Rate Per 100,000 in US and KY, by Age, 2016

Note: Unstable values in KY after age 79, rates could not be calculated.

Who is at risk for suicide death? Looking at means.

National (2016) KY (2016)

Understanding the connection: suicide and opioid abuse/overdose10(CDC, 2016)

65%

22%

8%5%

Firearm Suffocation

Drug Poisoning Other

51%

26%

11%12%

Firearm Suffocation

Drug Poisoning Other

In summary: Who is at risk for suicide death?

Men

Whites and American Indian/Alaskan Natives

Middle-aged (approx. 26-54)

Those with access to firearms


Who is at risk for suicide attempts?

Women are 1.2 times more likely to attempt suicide than men.

Those aged 18-25 are more likely to attempt suicide than those over the age of 26.

Adults with a past year substance use disorder.

Those who made an attempt were more likely to use poisoning or cutting than other methods.

Understanding the connection: suicide and opioid abuse/overdose12(AFSP, 2018; NSDUH, 2016)

Suicide in Health Care Settings

45% of those who died by suicide had contact with primary care providers in the month before death.

Over 70% of older adults who died by suicide saw primary care provider within 1 month of death.

In contrast, an estimated 33% of people who died by suicide had contact with mental health services in the month before death.


(Luoma et al., 2002)

INFORMATION ON OPIOID ABUSE AND OVERDOSE


Opioid Abuse: Youth and Adults (2016)

11.8 Million People (≥12) Abused Opioids in 20161

11.5 Million Abused Prescription Opioids

(97.4% of all people who abused opioids)

948,000 Used Heroin

(8% of all people who

abused opioids)

641,000 Used Heroin and Abused Prescription Opioids

(5.4% of all people who abused opioids)

1Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health (NSDUH), 2017.Understanding the connection: suicide and opioid abuse/overdose (CBHSQ, 2017) 15

Opioid Overdose – Kentucky and US


Age

Ad

just

ed D

eath

Rat

e Pe

r 1

00

,00

0 P

erso

ns

(NIH, 2018)

Who is at risk for opioid overdose? Looking at men and women.


Age Adjusted Opioid Overdose Death Rate Per 100,000 in US and KY, by Sex. 2012-2016

0

5

10

15

20

25

30

35

2012 2013 2014 2015 2016

Men (KY) Women (KY) Men (US) Women (US)

MEN (US)

(Kaiser Family Foundation, 2018)

MEN (KY)

WOMEN (KY)

WOMEN (US)

Deaths of Despair (Case & Deaton, 2017)

in all-cause mortality of middle-aged white, non-Hispanic men & women (1999-2015)

in drug overdoses, suicides, and alcoholic-related liver mortality, especially among those with a high school degree or less

Slide 18

Understanding the connection: suicide and opioid abuse/overdose

WHERE TO FIND DATA ON SUICIDE ATTEMPTS, SUICIDE DEATHS, OPIOID ABUSE, AND OPIOID OVERDOSE.

Understanding the connection: suicide and opioid abuse/overdose 19

Web-Based Resources from Vital Statistics

Web-based Injury Statistics Query and Reporting System (WISQARS), and Wide-Ranging Online Data for Epi Research (WONDER)

National Violent Death Reporting System (NVDRS)


National Surveys

SAMHSA’s National Survey on Drug Use and Health

CDC’s Youth Risk Behavior Surveillance System


Real-Time Surveillance: ESSENCE

Uses free-text categories of chief complaints and discharge diagnoses to monitor overdoses and suicides.

Can provide a snapshot of dates and times when a particular diagnosis was statistically higher than would be expected.



Exploring the connection between Opioid Abuse,

Overdose, and Suicide

Suicide by Method (2015)

8% Other

50% Firearms

27% Suffocation

15% Poisoning

0%

5%

10%

15%

20%

25%

30%

35%

40%

Poisoning Suicides by Substance –27 States (2015)3

Means of Suicide, United States3

3Centers for Disease Control and Prevention, National Violent Death Reporting System (NVDRS), 2016. Understanding the connection: suicide and opioid abuse/overdose (CDC, 2016) 24

Prescription Drug Abuse and Suicidal Behaviors: Adults

25

3.0 2.9 3.2 3.2 3.2 3.3

8.09.3 8.8 8.4

10.5 10.8

0.0

15.0

30.0

2011 2012 2013 2014 2015 2016

No Rx drug abuse Rx drug abuse 1+ time in lifetime

% Adults (18+) Who Report Having Serious Thoughts of Suicide in

the Past Year by Lifetime Nonmedical Prescription Drug (including

Opioid) Abuse (2011-2016)1

Understanding the connection: suicide and opioid abuse/overdose (CBHSQ, 2017)

From the Research…

Adults who receive high doses of opioids are at increased risk for suicide

Adults who abuse opioids weekly or more are more likely to engage in suicide planning and attempts

Adults who have an opioid use disorder are 13x more likely to die by suicide than the general population

Understanding the connection: suicide and opioid abuse/overdose26(Ilgen et al., 2016; Ashrafioun et al., 2017; Wilcox et al., 2004)

How does chronic pain fit in the connection between opioids and suicide?

Chronic pain, which may or may not be treated with opioids, is associated with an increased risk of suicide.

Some factors may increase suicide risk among chronic pain patients:

Pain severity

Perceived burdensomeness

Understanding the connection: suicide and opioid abuse/overdose27(Shim E-Song, 2017; NSSP, 2012)

Opioids and Suicide: Three Possible Links


Higher doses of opioids offer increased access to lethal means.

Opioids have disinhibiting effects, increasing the likelihood of acting on suicidal impulses.

People who take higher opioid doses share other characteristics – like pain or depression - that explain the link with suicide.

Limitations to Overdose and Suicide Death Data


Intentionality Continuum

When classifying a death as a suicide, a coroner or ME has to determine two things:

1.Did the person know that the dose was likely to be lethal? 2.What was the person’s intent?

This intent question is one of the most challenging aspects of our opioid/suicide death data.

Determining Intent in a Drug-Related Death

Manner of Death (MOD) classification include:

• Homicide

• Natural causes (disease)

• Suicide

• Accident (unintentional)

• Deaths of undetermined intent

• Deaths of unknown causes


Where we

really struggle

to classify

drug-related

deaths

Undercounting of Suicides

oDecedents who are Black or Hispanic

oYounger decedents (ages 15-34)

oDecedents with lower levels of education (high school diploma or less)

oDecedents without a history of psychiatric co-morbidity

oCases where a suicide note was not present

31

• Specific groups may be disproportionately affected

by the undercounting of suicides. Suicide

undercounting may be more common among:

Rockett et al., 2010Understanding the connection: suicide and opioid abuse/overdose24

Implications for Practice

We are likely underestimating the number of opioid-related deaths that are actually suicides. And this matters because:

This underestimation is not random – some groups are affected more than others.

We use data for planning where we direct prevention efforts.

We use data for evaluating the outcomes of our prevention efforts.


Summary: What do we know about the link between opioid abuse, opioid overdose, and suicide?

Degree of opioid involvement matters.

The actual “why and how” connecting opioids and suicide is not well-understood.

Our understanding on the connection between opioids and suicide is limited because of trouble with our death data.



Opioids and suicide: What we know about risk


Opioid Abuse: Factors that Increase Risk

• Physical health problems

o Chronic pain

o Headaches

• Social isolation

• Trauma/Adverse childhood experiences

• Behavioral health problems

o Depression

o Anxiety

(Rosenbalum et al., 2007; Tani et al., 2001; Austin et al., 2018)


Suicide: Factors that Increase Risk

• Physical health problems

• Behavioral health problems

• Social isolation

• Trauma

o Adverse childhood experiences

o Historical trauma

(NSSP, 2012; Hall Lande et al., 2007)


Shared Factors for Opioid Abuse and Suicidality

Opioid Abuse Suicidality

Intersection

Physical Health

Problems

Behavioral Health

Problems

Trauma/Adverse

Childhood Experiences

Social Isolation


Shared risk factors in target populations

Older AdultsAdolescents

Men in the Middle Years

Service Members and Veterans

Use the information to coordinate prevention efforts

Benefits to a coordinated approach to suicide and opioid abuse/overdose prevention:


• Focuses on those at

highest risk

• Avoids duplication of

effort

• Provides good value for

prevention dollars

EXAMPLES FROM THE FIELD


Public Health Approach to Prevention

What is needed to lower the rates of opioid overdose and suicide death is a comprehensive approach to prevention with national-level buy-in.

Understanding the connection: suicide and opioid abuse/overdose

What is a public health approach to prevention?

Population focus

Starts and ends with data

Upstream and downstream prevention efforts

Aim: reduce morbidity and mortality


The Public Health Model

Define the problem

Identify risk & protective factors

Develop & test prevention strategies

Assure widespread adoption

Selected Injury-Related, Age-adjusted Death Rates (2000-2016)

0

5

10

15

20

Rate

pe

r 1

00

,00

0 p

op

ula

tion

Year

Motor Vehicle Deaths

Suicide

Unintentional

Drug Poisoning

Homicide

5Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Understanding the connection: suicide and opioid abuse/overdoseCDC, 2017 43

Colorado National Collaborative

A public health approach with the goal of reducing suicide by 20% by 2024, while also tackling opioid overdose and other causes of premature mortality.

Uses a public facing data dashboard to allow county-level analysis of who is at risk for death by suicide.

Uses an environmental scan to identify existing activities related to increasing social connectedness, increasing help-seeking, and promoting evidence based treatment.

Looking at the gaps: Who is at risk and is being missed by current programming? How can we fill those gaps?


Another example: Mystic Valley Public Health Coalition


• Examined data to determine who is at increased risk for premature death – particularly from opioid overdoses.

• Identified and publicized existing services.

• Planned upstream prevention services to reduce suicide and opioid overdose.

How can you use this information?


What can health systems do?

Ensure that pain specialists and primary care providers screen for suicide and opioid overdose risk, using validated screening and assessment tools.

Facilitate safe care transitions through linking to behavioral health providers, creating a safety plan, and working to reduce access to lethal means.

Consider non-medication strategies for pain management, including cognitive behavioral therapy and complementary or alternative approaches (yoga, acupuncture)

Engage partners (employers, faith communities) to get help in increasing awareness of non-medication strategies for pain management.


Other active roles you can play…

Strengthen access to & delivery of care

Create protective environments

Connect people within their communities


Stone et al., 2017

Other active roles you can play…


Teach coping and problem solving skills

Identify and support people at risk

Prevent future risk

Stone et al., 2017

How Can You Strengthen Community-based Prevention Efforts?

Reach out to existing partners (e.g. clinics, schools, law enforcement)

Engage new partners (faith leaders, universities/schools, local businesses)

Utilize existing community outreach resources on the Action Alliance website (PowerPoint presentations, handouts, talking points)

Help your partners develop a robust opioid response (that incorporates suicide prevention)


More Resources: What Can You Do?

51

Visit the Suicide Prevention Resource Center website: http://www.sprc.org/ to learn more about the warning signs of suicide, suicide prevention efforts in your state, and other helpful resources.

Save the National Suicide Prevention Lifeline number:

1-800-273-TALK (8255). The Lifeline provides 24/7, free and confidential support for people in distress, prevention and crisis resources for you or your loved ones, and best practices for professionals. An online chat option is also available: https://suicidepreventionlifeline.org/chat/

Learn about the Action Alliance and its partners’ #BeThere collective messaging effort that provides ways you can take action to support a person who is struggling or in crisis: http://actionallianceforsuicideprevention.org/bethere

1

2

3

http://www.sprc.org/

https://suicidepreventionlifeline.org/chat/

http://actionallianceforsuicideprevention.org/bethere


Questions and Discussion

ReferencesMcKinlay J. (1979). A case for refocusing upstream; the political economy of illness. In: Gartley J, ed. Patients, Physicians and Illness: A Sourcebook in Behavioral Science and Health. New York: Free.

Center for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2005) [cited 2018 11 (Oct.) 30]. Available from URL: www.cdc.gov/injury/wisqars

NSDUH (2018) Results from the National Survey on Drug Use and Health: Detailed Tables. Available from URL: https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf

American Foundation for Suicide Prevention (2018). Suicide statistics. URL: https://afsp.org/about-suicide/suicide-statistics/

Luoma, J.B., Martin, C.E., & Pearson, J.L. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916.

Shim, E., Song, YW, Park, SH, Lee, KM, Go, DJ, & Hahm, BJ. (2017). Rheumatic disease: the mediating role of depression, perceived social support, and perceived burdensomeness. International Journal of Behavioral Medicine, 24(4), 501-512.


http://www.cdc.gov/injury/wisqars

https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf

https://afsp.org/about-suicide/suicide-statistics/

ReferencesCenter for Behavioral Health Statistics and Quality. (2016). 2015 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf

NIH (2018). Opioid overdose deaths by gender. Retrieved from: https://www.kff.org/otheNIH (2018).

Opioid-Related Overdose Deaths. Opioid Summaries by State. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/kentucky-opioid-summary

Kaiser Family Foundation r/state-indicator/opioid-overdose-deaths-by-gender/?dataView=2&activeTab=graph&currentTimeframe=0&startTimeframe=4&selectedDistributions=male--female&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D,%22states%22:%7B%22kentucky%22:%7B%7D%7D%7D&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Case, A., & Deaton, A. (2015). Rising morbidity and mortality in mid-life among white non-Hispanics in the 21st century. Proceedings of the National Academy of Sciences, 112(49), 15078-15083.

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control (2017). Web-based Injury Statistics Query and Reporting System (WISQARS) Fatal Injury Reports, National and Regional, 1981 - 2016. Retrieved fromhttps://webappa.cdc.gov/sasweb/ncipc/mortrate.html


https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2016/NSDUH-DetTabs-2016.pdf

https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state/kentucky-opioid-summary

ReferencesCenter for Behavioral Health Statistics and Quality. (2017). 2016 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, Rockville, MD.

Ilgen, M.A., Bohnert, A.S.B., Ganoczy, D., Bair, M.J., McCarthy, J.F., & Blow, F.C. (2016). Opioid dose and risk of suicide. Pain, 157(5), 1079-1084. https://www.slideshare.net/101N/opioid-dose-risk-of-suicide

Ashrafioun, L., Bishop, T.M., Conner, K.R., & Pigeon, W.R. (2017). Frequency of prescription opioid misuse and suicidal ideation, planning, and attempts. Journal of Psychiatric Research, 92, 1-7. http://www.journalofpsychiatricresearch.com/article/S0022-3956(16)30183-2/fulltext

Wilcox, H.C., Conner, K.R., & Caine, E.D. (2004). Association of alcohol and drug use disorders and completed suicide: an empirical review of cohort studies. Drug and Alcohol Dependence, 76 Suppl:S11-9.

Rockett IRH, Wang S, Stack S et al. (2010). Race/ethnicity and potential suicide misclassification: Window on a minority suicide paradox? BMC Psychiatry,10(1), 35.

Rosenblum, A., Parrino, M., Schnoll, S. H., Fong, C., Maxwell, C., Cleland, C. M., . . . Haddox, J. D. (2007). Prescription opioid abuse among enrollees into methadone maintenance treatment. Drug and Alcohol Dependence, 90(1), 64–71

Ford, J. A., & Rigg, K. K. (2015). Racial/Ethnic differences in factors that place adolescents at risk for prescription opioid misuse. Prevention Science: The Official Journal of the Society for Prevention Research, 16(5), 633–641.25


https://www.slideshare.net/101N/opioid-dose-risk-of-suicide

References

• Austin, A.E.,& Shanahan, M.E. (2018). Association of childhood abuse and neglect with prescription

opioid misuse: Examination of mediation by adolescent depressive symptoms and pain. Children and

Youth Services Review, 86, 84-93.

• Tani, C.R., Chavez, E.L., & Deffenbacher, J.L. (2001). Peer isolation and drug use among white non-

Hispanic and Mexican American adolescents. Adolescence, 36(141), 127-139.

• Hall-Lande, J.A., Eisenberg, M.E., Christenson, S.L., & Neumark-Sztainer, D. (2007). Social isolation,

psychological health, and protective factors in adolescence. Adolescence, 42(166), 265-286.

• National Strategy for Suicide Prevention. (2012). 2012 National Strategy for Suicide Prevention:

Goals and Objectives for Action: A Report of the U.S. Surgeon General and of the National Action

Alliance for Suicide Prevention. https://www.ncbi.nlm.nih.gov/books/NBK109909/

• Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, S., and Wilkins, N. (2017). Preventing

Suicide: A Technical Package of Policies, Programs, and Practices. Atlanta, GA: National Center for

Injury Prevention and Control, Centers for Disease Control and Prevention.


https://www.ncbi.nlm.nih.gov/books/NBK109909/

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www.actionallianceforsuicideprevention.org

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