It’s a question that’s lurked in the background of our continuing discussion of opioid overdose: how many of the fatal kind should actually be listed as deliberate suicide, versus “unintended” or “undetermined”. It’s an important issue for prevention, because if severe depression is a common driver, then our approach to the prevention of overdose fatalities– a current focus– would need to be adjusted to reflect that changed reality.

Researchers have long suspected a connection between opioid addiction and mental health problems, perhaps beyond that found with other common substances. Here’s an article from the New England Journal of Medicine by Maria Oquendo and Nora Volkow. The latter, by the way, is Director of the National institute on Drug Abuse.

From their article: “Among persons with OUD, the suicide risk was 87 in 100,000— six times the general U.S. population rate of 14 in 100,000; even after controlling for other suicide risk factors such as coexisting psychiatric diagnoses, OUD more than doubled the risk of suicide among women and increased the risk among men by 30%.”

The increased incidence of depression, anxiety, and other psychiatric symptoms linked to OUD may also help to account for high rates of relapse among patients, post-treatment, versus other substance disorders. It  does represent an argument for more consistent access to mental health resources for patients with OUD. That includes psychiatric medication, but also suggests benefits from closer monitoring, longer term transitional living programs, and supportive psychotherapy– all of which are largely missing from the continuum of care in many regions.

I entered the field of addiction treatment during the mature stages of an opioid epidemic in the San Francisco Bay Area and was immediately exposed to the atmosphere of failure and hopelessness that seemed to infect the community of heroin addicts. I brought it up in group one day and the discussion was surprisingly animated.

“Aw, nobody believes I can stay straight anyway, so why bother trying?” complained one young user. “Well, if you don’t believe you can do it, maybe that’s where they’re getting the idea,” countered another, cleverly enough I thought. A third participant recalled her earlier tenure on methadone maintenance, when she was able to keep a job and feed her family but still battled depression on a daily basis. She cited that as a reason she eventually left the program. She was still in a funk and it wasn’t improving.

The best summary, however, came from a man who’d been using heroin for twenty years. He described an incident where he was standing in line to buy cigarettes at a convenience store and found himself pondering a strange question: suppose the place got robbed and he was accidentally shot and killed in the process — would his death represent any loss? “Would I really care?” he told the group.

That’s why I think that as the nation continues its push to enroll more people in medication-assisted treatment, we should also redesign the usual system of care to include services that address neglected aspects of recovery from OUDs — depression, anxiety, and the potential for suicide.

We assess that potential on admission, mainly to eliminate it, forgetting that it could become an issue, often without warning, in future. If it does, what will we do about it?