Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

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In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

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Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

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Christianity Today: How Good Church People Become Addicts – and How They Recover

Timothy King’s article Just Say No to Shame in the December 2016 issue of Christianity Today includes a very insightful comment: “My recovery from opioid addiction began when I realized my addiction had chosen me.” King fell to the disease of opioid addiction following suffering from acute necrotizing pancreatitis caused by a surgical procedure. He said, “I had known pain before: crutches, casts, and stitches. But until this moment, pain had always been experienced as something outside of myself. Now it was all that was left of me.”

An opioid, from the root word opium, is a class of pain-relieving drugs that can vary in intensity from fentanyl (extreme) to codeine (mild). According to the Department of Health and Human Services, more than 240 million prescriptions were written for legal opioids in 2014 – more than enough for every adult in the United States to have their own bottle. From 1999 to 2014, the period in which opioid overdose deaths quadrupled, so too did the sales of prescription opioids.

The widespread nature of the opioid epidemic that reaches across typical class, race and geographical stereotypes has challenged myths of who drug addicts are. It has also widened the lens, revealing more moral actors participating in the crisis beyond the addict. Years of distorted public policy, overworked and unrestrained doctors, intentionally misleading pharmaceutical marketing, and even watered-down theology that reduces people to disembodied moral characters instead of whole human persons created in the image and likeness of a good God, have all contributed through sins of both omission and commission.

Many opioid addicts began using these drugs for legitimate physical ailments, merely following their doctor’s orders. In fact, the American Society of Addiction Medicine reports that four out of five heroin addicts started with prescription opioid medications, with nearly all reporting that they eventually switched to heroin because of the price.

Our mental picture of an addict should include the high school honors student who breaks her arm skateboarding and is prescribed an opioid by her doctor. Or the middle-aged factory or construction worker who has permanent back pain from his job and is prescribed an opioid by an overworked doctor who misses the fact that his patient is severely depressed. Or a white, college-educated, employed, middle-class Christian (as in my case, and the case of Timothy King, the author of the article) from a good family who grew up in small-town America.

When King’s doctor informed him he had become addicted to pain medication, he told King, “That isn’t a judgment on you. I’m not saying you’ve done anything wrong or that you aren’t still in pain. But we’ve been giving you this pain medication for so long, your body is now dependent on it. It has gone from helping you to hurting you.” The doctor told King he was not going to just take the pain medication away when he needed it. But he asked King to commit to taking less whenever he could. The doctor said, “For a while you couldn’t have made it without the pain medicine. Now to fully heal, you need to eventually stop taking it.”

In July of this year, Congress passed legislation to address the opioid crisis and heroin epidemic. Even the language  of “crisis” and “epidemic” to describe the bill indicates a shift in mentality. The legislation acknowledges a growing medical consensus that the addict is subject to a disease – one with deep biological and psychological roots that often preclude individual choice. This landmark legislation marked an important step forward in reorienting public policy to reflect this new consensus. Framing addiction as a chronic disease does not remove the moral choices involved, but gives us a broader framework for understanding them. We can’t ignore the reality of our bodies, and when it comes to opioid addiction (as well as other addictions), part of the effect of those chemicals is to actually rewire the brain, making it more difficult, if not nearly impossible, to change patterns of thought and behavior.

King discusses one commonly used analogy helping us understand addiction: heart disease. Like all analogies, it doesn’t explain everything, but it has the virtue of pointing out how clogged arteries cannot be cleared up by giving a pep talk to the patient or urging him to stop breathing so hard after climbing a set of stairs. Its causes are found in a mix of hereditary, environmental, and lifestyle choices. It’s also helpful to think about how often our physical state and surroundings influence our actions.

But the sense that addiction is solely a moral problem is hard to eradicate. After I clearly understood my addiction as a disease (which took nearly four decades and several encounters with the criminal justice system), I still battle internally with my self-image to this day. I grew up with the “Just Say No” anti-drug campaigns aimed at warning youth about illegal drugs. In that model, those with moral fortitude say “no,” and moral degenerates say “yes.” Those who said “no” received praise, and those who said “yes” were shamed and punished.

King recalls how he began to back down from taking opioid painkillers. He writes, “I removed the fentanyl patch first and switched to taking only Dilaudid. Within a day I could again feel my body in ways I did not realize I had been missing. At the same time, it felt as if a thick protective comforter had been ripped off from around me while I lay shivering and naked on my bed. Pain that had been blunted refocused and pressed out from the inside. The doctor was right. I could handle the pain now without the same levels of opioids. But I couldn’t  have continued my recovery if it were all up to the strength of my will alone.” King added, “So much more powerful than saying ‘no’ to an opioid was the opportunity to say ‘yes’ to a slow return to a life of flourishing.”

King said goodbye to narcotic pain medication, but indicated it was not an easy goodbye. He said the feeling was like the tremor in your hand when your blood sugar drops. Desire spreads out to every cell of your body as if each one is making its own demand, aching and promising to be satisfied with “just a little more.” Feelings of withdrawal and the troubled sleep that often comes with them are typically intense for the first few days. They can flare up even months down the road as a reminder of what had been, and the perilously thin line between you and the mounting numbers of long-term addicts and overdose victims. For me, I always thought I could control my usage. I was convinced I would never “take too much” and overdose. And yet it happened. I don’t recall anything from the moment I became unresponsive in my parents’ living room, through the ambulance ride to the ER, and ripping out my IV, to being sedated with haldoperidol. I woke up the next morning in a hospital room.

King relates, “I’ve realized that the word ‘addict’ is a particularly useful descriptor for who I have always been. I always resonated with Paul’s lament: ‘I do not do the good I want to do, but the evil I do not want to do – this I keep doing.’ (Romans 7:19) Some who have never experienced the furious grip of chemical dependence are tempted to split the world into addicts and non-addicts…morally bad and morally good.” He added, “I did not realize how fully I had embraced this view until faced with my own opioid addiction.” For me personally, I will admit I didn’t know I could have an addiction problem and still be a good person.

While addiction science has made strides, there is still no silver bullet. Already there are stories of innovative addicts who have found new ways to abuse the medications intended to help them. Any approach that reduces addiction to a mere problem of brain chemistry and fails to acknowledge humans as moral actors will ultimately fail. But leading researchers and those discussing public initiatives have gone a long way to acknowledge the importance of a both/and methodology.

Churches can be cultural epicenters for shifts in societal norms. The longer that addiction is seen as a struggle for the “sinners out there” and not at the heart of the struggle of each and every one of us, the longer this problem will make headlines and remain in the shadows. Remember, sin takes its deepest root in the cover of darkness where it is never given a name.  King concludes, “When our affliction is named for what it is and brought into the light, that’s when darkness may be overcome.”